Accessibility Project Demographics & Follow Up Form
This demographics form is required for any services provided under the Accessibility Project Grant through the New Mexico Coalition Against Domestic Violence 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 subgrant #120 2015-WF-120 awarded by the NMCVRC for the STOP Formula Grant Program. The opinions, findings, conclusions, and recommendations expressed in the program 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.