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Service Referral Questionnaire

OMB Control Number 1103-0066


Join Our Service Referral Network

If you work with victims of crime, the National Center wants to make sure we refer callers to you. Complete our on-line Service Referral Questionnaire to get referrals to your organization.

For More Information about our program, e-mail the Victim Services Staff at sp@ncvc.org
Background Information
Agency Name:
Contact Person:
Title:
Address:
City:
County:
State:
Zip: - (+4 optional)
Counties Served:
Hours:
Office Phone: - -
Hotline: --
TDD/TTY: - -
Toll-Free: - -
Fax: - -
E-mail:  
Homepage:
Languages, ohter than English, in which you provide services:
Agency Type:
VOCA:
Groups Served:
  Males   Females
Special needs victims your agency is trained or equipped to serve:
Chinese
Services Offered:
Court Accompaniment
HIV-Emergency Services
Types of Crime Victims:
Child Abuse/Neglect
Domestic Violence Stalking
Gang Violence
Non-criminal event
Other Comments:
DISCLAIMER
I understand the National Center for Victims of Crime will be using the above information to direct victims, service providers and general callers to our services. I am authorized by this agency to give permission to the National Center for Victims of Crime to use and release said information.
Paperwork Reduction Act:
The COPS Office and its grantees try to create forms and instructions that are accurate and easily understood. The public burden for this form is estimated at 15 minutes per respondent, including time for reviewing instructions and completing this form. There is no estimated record keeping burden associated with the information collection. The COPS Office welcomes your comments regarding this burden estimate or any other aspects of this form, including suggestions for reducing this burden.
Send comments to: COPS Office, PPSE Division, 1100 Vermont Avenue, NW, Washington, DC 20530,and to the Office of Management and Budget, Paperwork Reduction Project: OMB No. 1103-0066, Washington DC 20530.
OMB Number 1103-0066
Expiration date 7/31/07
Respondents are not required to respond to this information collection unless it displays a currently valid OMB Control Number.

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Contacts: 2000 M Street NW, Suite 480, Washington, D.C. 20036 phone: 202-467-8700 fax: 202-467-8701, email: webmaster@ncvc.org. 
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