Governor’s Crime Commission

Domestic Violence/Sexual Assault Service Plan

Agency Name:______County/Counties Served:______

A. Funding Sources (FY July 1, 2013 to June 30, 2014)

Council for Women

  • Marriage License $______
  • Displaced Homemaker $______
  • Divorce Filing Fees $______
  • DV/SA $______

Department of Health and Human Services

  • Family Violence Prevention $______
  • Rape Prevention Education $______

Governor’s Crime Commission

  • Victims of Crime Act $______
  • Violence Against Women Act $______

United Way $______

Thrift Store $______

Foundations $______

Emergency Shelter Grants $______

City/County Funds $______

Federal Funds $______

Fees from Services $______

Donations $______

Other (Describe)______$______

Total Funding $______

Percent of funding from unrestricted funds: ______%

Budget Category I Most Recent Complete Fiscal Year I Current Fiscal Year I Next Fiscal Year

(estimated) (projected)

Year ______

Total Income $______$______$______

Total Expenses $______$______$______

Surplus/Deficit $______$______$______

B. Services Provided (Indicate with an“X”the best description for your agency profile)

______Stand Alone DV service provider ______Stand Alone SA service provider

______Combined DV/SA service provider ______Other (describe) ______

______Multi-Agency (e.g., DV SA services, batterers’ treatment services, etc.)

C. Fundraising History

Please provide the amount you raised via fundraising activities for the following years:

  • 2010 $______
  • 2011 $______
  • 2012 $______

Please provide the PROJECTED amount you expect to raise via fundraising activities for the following years:

  • 2013 $______
  • 2014 $______

Describe your largest fundraising event, amount raised each year, and number of years for the event:

D. Personnel

Total number of employees: Full-Time: Part-Time:______Volunteers:______

List each titled position for staff (please include all positions in your agency):

______

______

______

Does the executive director conduct annual performance appraisals for staff? ______

Does the agency board conduct annual performance appraisals for the executive director?______

How often does your board meet? ______

E. Victims Served Last Year (Please provide the following numbers of UNDUPLICATED victims served:

Victim Category DV SA Other (describe) Totals

Adult Victims Served______

Child Victims Served______

Services Offered (Indicate with an “X”) Yes No

Advocacy (referrals, jails, courts, corrections)______

Crisis Hot Line______

Children’s Services______

Counseling______

Case Management______

Legal Assistance______

Transportation Services______

Employment Referrals______

Job Skills Training______

Food Pantry______

Transitional Housing______

Hospital Accompaniment______

Shelter______

Group Support______

Victims’ Compensation

Service Details (Indicate the number served) 2 Years Prior Last Year

Shelter Capacity______

Average Length of Shelter Stay______

Number of Women Served (residential)______

Number of Children Served (residential)______

Number of women Served (non-residential)______

Number of children Served (non-residential)______

Number of Men Served______

Number of Shelter Sites ______

Explain make-up of shelter sites if more than one (1) exists: ______

Ethnicity Percentage

Caucasian ______%

Hispanic/Latino ______%

Asian ______%

African American ______%

Native American ______%

Other ______% Specify ______

Age Percentage

Youth (up to 18) ______%

Adult (19 – 50) ______%

Elderly (over 50) ______%

Gender Percentage

Male ______%

Female ______%

Other ______%

F. Organizational Diversity and Gender

Please denote diversity and gender composition for the following positions:

Board / Staff / Volunteers
Female I Male / Female I Male / Female I Male
Asian Pacific
African American
Caucasian
Latino
Native American
Other

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North Carolina Governor’s Crime Commission

DV/SA Service Plan