Home > Victim Services Victim Services Federal VOCA Reporting VICTIM INFORMATIONDate of Service* Was this a group or an individual?*Select OneGroupIndividualGroup NameVictim Name First Last 3. Has this victim received services in the past?*All victims reached between October and December should be counted as new.Select OneYesNo4A. Race/Ethnicity for NEW Victims4a1. American Indian/Alaska Native4a2. Asian4a3. Black/African American4a4. Hispanic or Latino4a5. Native Hawaiian and Other Pacific4a6. White Non-Latino/Caucasian4a7. Some Other Race4a8. Multiple Races4a9. Unknown - NOT REPORTED by victim4a10. Unknown - NOT TRACKED by agency4B. Gender Identify for NEW victims4b1. Male4b2. Female4b3. Unknown - NOT REPORTED by victim4b4. Unknown - NOT TRACKED by agency4b5. Other (please specify below)4b6. If "Other" please describe here:4C. Age for NEW Victims4c1. 0-1242c2. 13-174c3. 18-244c4. 25-594c5. 60 and Older4c6. Unknown - NOT REPORTED by victim4c7. Unknown - NOT TRACKED by agency5. Type of Victimization*Check all that apply.5a. Adult Physical Assault (Includes Aggravated and Simple Assault)5b. Adult Sexual Assault5c. Adults Sexually Abused/Assaulted as Children5d. Arson5e. Bullying (Verbal, Cyber or Physical)5f. Burglary5g. Child Physical Abuse or Neglect5h. Child Pornography5i. Child Sexual Abuse/Assault5j. Domestic and/or Family Violence5k. DUI/DWI Incidents5l. Elder Abuse or Neglect5m. Hate Crime: Racial/Religious/Gender/Sexual Orientation, etc.5n. Human Trafficking: Labor5o. Human Trafficking: Sex5p. Identity Theft/Fraud/Financial Crime5q. Kidnapping (Non-Custodial)5r. Kidnapping (Custodial)5s. Mass Violence (Domestic/International)5t. Other Vehicular Victimization (e.g., Hit and Run)5u. Robbery5v. Stalking/Harassment5w. Survivors of Homicide Victims5x. Teen Dating Victimization5y. Terrorism (Domestic/International)5aa. Other (describe below)5bb. If "Other" above describe here:5cc. If "Hate Crime", please describe what type here (Racial/Religious/Gender/Sexual Orientation, etc):6. Did this victim present with more than one type of victimization (secondary victimization)*YesNo7. Special classification of victims7. N/A7a. Deaf/Hard of Hearing7b. Homeless7c. Immigrants/Refugees/Asylum Seekers7d. LGBTQ7e. Veterans7f. Victims with Disabilities: Cognitive/ Physical /Mental7g. Victims with Limited English Proficiency7h. Other (describe below)7i. If "Other" above please describe here:DIRECT SERVICES8. Was assistance with a victim compensation application provided?8. Yes8. No9. Type of Service Provided9a. Information and Referral9a1. Information about the criminal justice process9a2. Information about victim rights, how to obtain notifications, etc.9a3. Referral to other victim service programs9a4. Referral to other services, supports, and resources (includes legal, medical, faith-based organizations, address confidentiality programs, etc.)9b. Personal Advocacy/Accompaniment9b3. Law enforcement interview advocacy/accompaniment9b4. Individual advocacy (assistance in applying for public benefits, return of personal property or effects)9e. Crimanl/Civil Justice System Assistance9e1. Notification of criminal justice events (e.g., case status, arrest, court proceedings, case disposition, release, etc.)9e2. Victim impact statement assistance This iframe contains the logic required to handle AJAX powered Gravity Forms.