BATTERER INTERVENTION PROGRAM DATA

In order to measure outcomes of court ordered referrals to certified Batterer Intervention Programs, the Department of Corrections is requesting that each BIP submit statistics on a monthly basis.

* Note: fields marked with an asterisk (*) MUST be filled in.

Program

Name of Program*
Person Submitting Report*
Telephone number*
Email address

Reporting Period

Month*

Year* (Please enter all four digits, e.g 2009)

Participation

Number of intakes
Number currently enrolled*
Number of men who completed the program this month
Number of men who left without completing the program
Number of men who completed but were required to attend the program again
Number of men who re-offended and went to jail while attending the program

Number of non-white participants from each culture

Asian
Black

Hispanic
Native American

Total number non-white participants*

Incoming Referrals

Number of referrals from Probation
Number of referrals resulting from filings or conditions of release
Number of referrals from DHHS
Number of PFA referrals
Number of self-referrals
Number of referrals from Mental Health
Number of referrals from District Attorney
Number of transfers from other BIPs

Special Needs

What accomodations, if any, were made within the program for example, for men for whom English was a second language, men from a different culture, hard of hearing, or who had difficulty being in a group?

Special Need	Number of Men	Describe Accomodations Made
English as Second Language
Hearing Impairment
Mental Illness
Other
Total Number of Men with Special Needs*

Number of referrals to each service

Substance Abuse
Literacy
Parenting
Mental Health
Vocational
Employment
Housing

If you have questions about completing this form, contact Denise Giles by phone at 800 968 - 6909 or by email to: DENISE GILES

When you have completed this report, click the SUBMIT button to send it to the Department of Corrections. Press RESET to clear your entries and start over.

Corrections

BATTERER INTERVENTION PROGRAM DATA

What accomodations, if any, were made within the program for example, for men for whom English was a second language, men from a different culture, hard of hearing, or who had difficulty being in a group?