Accessibility Project Demographics & Follow Up Form

This demographics form is required for any services provided under the Accessibility Project Grant for reporting to the NM Crime Victims Reparations Commission. If you have any questions about this form, please contact

Service Date:
Agency: A value is required.
Person Requesting Services: A value is required.
Service Type Please select an item.
Victim Type: Please select an item.
Number of Secondary Victims Served: Secondary victims are those who are indirectly
affected by the violence – i.e., children, siblings, grandparents, etc.
Race/Ethnicity Please select an item.
Gender: Please select an item.
Age: Please select an item.
Relationship to Offender: Please select an item.
Person has Limited English Proficiency:
Please make a selection.
Person with disabilities:
Please make a selection.
Person is immigrant, refugee, or asylum seeker:
Please make a selection.
Person lives in a rural area:
Please make a selection.
Language Requested (if applicable)
Anything we can share with the funder about this use of funds to support the work:

NMCADV This project was supported by Grant Number 2011-WF-AX-0021 awarded by the New Mexico Crime Victims Restoration Commission and the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions and recommendations expressed in the publication/program/exhibition are those of the author(s) and do not necessarily reflect the views of the NMCVRC or the Department of Justice, Office on Violence Against Women.