Appendix D: Provider Inventory Survey

Section I: Agency Information

1. Contact Information
2. Is your agency:
   1. Public
   2. Private for profit
   3. Private non-profit

Section II: Victim Information

3. Please indicate the types of primary victims served by your agency
   1. Family Violence
   2. Sexual Assault
   3. Child Abuse
   4. Elder Abuse
   5. Aggravated Assault
   6. Assault
   7. Robbery
   8. Property (Burglary, Theft)
   9. Other (specify)
4. Please indicate the types of Secondary victims service by your agency
   1. Family Violence
   2. Sexual Assault
   3. Child Abuse
   4. Elder Abuse
   5. Aggravated Assault
   6. Assault
   7. Robbery
   8. Property (Burglary, Theft)
   9. Homicide
   10. Manslaughter
   11. Other (specify)
5. Does your agency collect information on the victims that you serve? If yes, proceed to question 6. If no, proceed to Section III.
6. What is the total number of victims served by your agency?
7. Indicate the number of victims served during calendar year 2001
   1. Anglo
   2. African-American
   3. Hispanic
   4. Asian
   5. Pacific Islander
   6. Native American
   7. Other
8. Please indicate the number of victims served during calendar year 2001
   1. Male
   2. Female
9. Indicate the number of victims served during calendar year 2001
   1. Elderly (65+)
   2. Children (0-17)
   3. Homeless
   4. Persons with Disabilities
   5. Undocumented residents

Section III: Service Information

10. What services does your agency provide to Adult Primary Victims?
    1. 24-Hour Hotlines
    2. Assistance in Filing Crime Victim Compensation Claims
    3. Case Management
    4. Civil Legal Assistance
    5. Crisis Counseling
    6. Death Notification
    7. Emergency Financial Assistance
    8. Follow-up Contact
    9. Group Treatment
    10. Information and Referral
    11. Justice Support/Advocacy
    12. Medical Services
    13. Parole/Probation Notification
    14. Personal Advocacy
    15. Shelter/Safe House
    16. Supported/Transitional Housing
    17. Telephone Contact Information and Referral
    18. Therapy
    19. Other (specify)
11. What services does you agency provide to Adult Secondary Victims?
    See List under Question 10.
12. What services does your agency provide to Child Primary Victims?
    See List under Question 10.
13. What services does your agency provide to Child Secondary Victims?
    See List under Question 10.
14. Does your agency maintain a waiting list for victim services? If yes, proceed to question 15. If no, proceed to question 16.
15. What specific victim services have waiting list and what is the average length of time a victim is on each list? (e.g. crisis counseling: 1 wk)
16. How many victims are denied services annually due to lack of agency resources?
17. Does your agency charge for services? If yes, check all that apply. If no, proceed to question 18.
    1. Client fees
    2. Sliding scale fees
    3. Bill crime victim compensation
    4. Bill other third party payers (insurance, Medicaid)
    5. Other (specify)
18. Does your agency have the ability to serve non-English speaking clients? If yes, proceed to question 19, If no, proceed to question 21.
19. In what non-English languages is your agency able to serve clients?
20. In what methods of service are the languages provided?
21. What are the top three services your clients request/need (as a result of their victimization) that your agency does not provide?
22. How do you think victim services could be improved in our community and/or what additional services are needed?

Section IV: Financial Information

23. Questions regarding your total agency budget and percent allocation to victim services.
    1. Total agency budget for 2001
    2. Percent of the total agency budget allocated to victim services
24. Please approximate the percent of the total agency budget that comes from the following funding sources:
    1. Federal
    2. State
    3. City
    4. County
    5. Client Fees
    6. Private Foundations
    7. Individual Donations
    8. Memberships
    9. Special Events
    10. Other (specify)
25. Is your agency experiencing or anticipating funding cuts?
    1. Yes, we have experienced funding cuts in the last year.
    2. No, we have not experienced funding cuts in the last year.
    3. Yes, we anticipate funding cuts next year.
    4. No, we do not anticipate funding cuts next year.
26. If your agency is experiencing or anticipating funding cuts, how will this impact specific victims services in your agency?
27. How many full time and/or part time employees does your agency employ that are devoted to servicing victims?
    1. Full time
    2. Part time
28. What is the total cost (salary, benefits, training, etc.) of victim services staff for your agency?
29. Additional Comments