PATH Annual Survey Revised. 9.16.2009

OMB No. 0930-0205
Reporting Burden For Local Providers using the Web Survey: 31 hours per annual
Exp. Date: TBD
response, including time for becoming familiar with the form and reporting requirements,
obtaining client and activity data, aggregating the data, recording the data onto preliminary forms, recording the data
onto the official form, reviewing the data for accuracy, validating the data, and revising the data in response to state
review.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to: SAMHSA Reports Clearance Officer; Paperwork Reduction Project
(0930-0205); 7th Floor, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is (0930-0205).

The PATH Program
ID# 9000
Help can be found by going to
the instructions section here.

For FY Beginning:

07/01/07

(mm/dd/yy)

For FY Ending:

06/30/08

(mm/dd/yy)

* Contact Person:
E-mail:
Phone:
Fax:
* The Contact Person should be the person to be contacted to answer any questions about the data.
Please provide their email address, phone, and fax. They may or may not be the principal PATH contact
for the PATH provider.

Save / Update Data and Move to Next Page

Survey Information for: The PATH Program - ID# 9000

If not readily available, please contact your fiscal department or state PATH contact for this information

Table A: Budget Information
A1.

Total annual dollar amount for services dedicated to persons who
are experiencing homelessless or risk of homelessnes AND serious
mental illness: (includes PATH federal funds, match funds, and
non-PATH funds)

Estimated
Actual

A2.

PATH Federal funds received from the State:
Estimated
Actual

A3.

Match funds from State, local, or other resources to support the
provision of PATH services:
Estimated
Actual

A4.

The number of staff supported by PATH federal funds and match
funds:
Estimated
Actual

A5.

The full time equivalent (FTE) of staff positions supported by PATH
federal funds and match funds: (Please see the definition of FTE in
the PATH Annual Report Provider Guide)

Estimated
Actual

A6.

Indicate the type of organization in which the PATH program
operates:

a. community mental health center
b. consumer-run mental health agency
c. other mental health agency

d. other social service agency
e. health care for homeless/other health agency
f. substance abuse treatment agency
g. shelter or other temporary housing resource
h. other housing agency
i. other
If other please specify:

Save / Update Data and Move to Next Page

Survey Information for: The PATH Program - ID# 9000

Table B: Persons Served
The annual reporting information should include unduplicated counts of persons during the fiscal
year. Table B is used to report the number of persons served by the PATH program. Please see the
"PATH Annual Report Provider Guide" for clarification on definitions.
B1.

Persons who are homeless and have serious mental illnesses
served by PATH funds and other sources.
Estimated
Actual

B2a.

Persons served by PATH federal and match funds-- outreach.
Estimated
Actual

B2b.

Number of outreach contacts who became enrolled during the
year as PATH clients.
Estimated
Actual

B2c.

Number of outreach contacts who did not become enrolled
during the year as PATH clients (Note: Item B2c = Item B2a - Item
B2b)

Estimated
Actual

B2d.

Number of outreach clients (in Item B2c above) not enrolled
because they have been found to be ineligible.
Estimated
Actual

B3.

Persons served by PATH-- enrolled PATH clients.
(Table B, Item B3)
Estimated
Actual

B4.

Total number of persons receiving any PATH-supported services
during the year.

(Note: Item B4 = Item B2c + Item B3)

Estimated
Actual

Please explain any items for which you received warnings in the box below.
Please reference the item number(s).

Save / Update Data and Move to Next Page

Survey Information for: The PATH Program - ID# 9000

Table C: Services Provided
The following services can be supported with PATH federal funds and match funds. Few PATH providers offer all of these
services.
Please check the appropriate type of funding for each service. If the service is 100% PATH federal funded, PATH federal
and match funded, or 100% PATH match funded please indicate the number of enrolled PATH clients who received the
service in the box to the right. If the service is not provided enter zero (0) for number of enrolled PATH clients. All numbers
must be less than or equal to the number of enrolled PATH clients reported in Table B.
Number of Enrolled PATH Clients Reported in Table B, Item 3 =
Number of Enrolled PATH
Clients

Type of Service:
Ca.

Cb.

Cc.

Cd.

Outreach services:

Ca1.

100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Screening and diagnostic treatment services:

Cb1.

100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Habilitation and rehabilitation services:

Cc1.

100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Community mental health services:
100% PATH funded

Cd1.
Partially PATH funded

Service provided but not PATH funded

Ce.

Cf.

Cg.

Ch.

Ci.

Cj1.

Service not provided

Alcohol or drug treatment services:

Ce1.

100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Staff training, including the training of individuals who work in
shelters, MH clinics, SA programs, and other sites:
100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Case management services:

Cg1.

100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Supportive and supervisory services in residential settings:
100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Referrals for primary health services, job training, educational
services, and relevant housing services:
100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Housing services: 1. Minor renovation, expansion, and repair of
housing:
100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Ch1.

Ci1.

Cj11.

Cj2.

Cj3.

Cj4.

Cj5.

Cj6.

Cj7.

Housing services: 2. Planning of housing:

Cj21.

100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Housing services: 3. The costs associated with matching eligible
homeless individuals with appropriate housing situations:
100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Housing services: 4. Technical assistance in applying for housing
assistance:
100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Housing services: 5. Improving the coordination of housing services:
100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Housing services: 6. Security deposits:

Cj31.

Cj41.

Cj51.

Cj61.

100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Housing services: 7. One-time rental payments to prevent eviction:
100% PATH funded

Partially PATH funded

Service provided but not PATH funded

Service not provided

Voluntary Outcome Measures

Cj71.

Number of Enrolled PATH
Clients

Ck1.

Voluntary Outcome Measure: 1. Housing (transitional, supportive, or
permanent):

Ck1a. Assisted

Estimated
Actual

%
Not reporting
Ck1b. Attained

Estimated
Actual

%
Not reporting

Ck2.

Voluntary Outcome Measure: 2. Income benefits:

Ck2a. Assisted

Estimated
Actual

%
Not reporting
Ck2b. Attained

Estimated
Actual

%
Not reporting

Ck3.

Voluntary Outcome Measure: 3. Earned income (employment):

Ck3a. Assisted

Estimated
Actual

%
Not reporting
Ck3b. Attained

Estimated
Actual

%
Not reporting

Ck4.

Voluntary Outcome Measure: 4. Medical insurance or coverage plans
(Medicaid, Medicare, and/or state/local plans):

Ck4a. Assisted

Estimated
Actual

%
Not reporting
Ck4b. Attained

Estimated
Actual

%
Not reporting

Ck5.

Voluntary Outcome Measure: 5. Primary medcal care:

Ck5a. Assisted

Estimated
Actual

%
Not reporting
Ck5b. Attained

Estimated
Actual

%
Not reporting

Save / Update Data and Move to Next Page

Survey Information for: The PATH Program - ID# 9000

Table D: Demographics
Include as much demographic information as is available on each enrolled PATH client. If
demographic information is not available for certain data elements, enter the clients into the "Unknown"
category for that data element. Some elements could change (i.e., age). Where available, information
should show the status of the person at first contact, even if the first contact occurred in a prior fiscal
year. However, for persons who have enrolled, left and then re-entered the service system, indicate
status upon re-entry.
Total sum for each category (e.g. age) must be equal to Table B, Item B3. Your entered Value =
D1ea. Age:
D1a. Less than 13 years:
D1b. 13-17 years:
D1c. 18-34 years:
D1d. 35-49 years:

Numbers Reported are:
Estimated

D1e. 50-64 years:
D1f.

Actual

65-74 years:

D1g. 75 years and older:
D1h. Unknown:
D2ea. Gender:
D2a. Male

Numbers Reported are:

D2b. Female

Estimated

D2c. Unknown

Actual

D3ea. Race/Ethnicity:
D3a.

American Indian or
Alaska Native

D3b.

Asian

Numbers Reported are:
Estimated
Actual

D3c.

Black or African American

D3d.

Hispanic or Latino

D3e.

Native Hawaiian or
Other Pacific Islander

D3f.

White

D3g.

Two or More Races

D3h.

Unknown

D4ea. Principal Mental Illness Diagnosis:
D4a. Schizophrenia and Related Disorders
D4b. Other Psychotic Disorders
Numbers Reported are:

D4c. Affective Disorders

Estimated
D4d. Personality Disorders

Actual

D4e. Other Serious Mental Illness
D4f.

Unknown or Undiagnosed Mental Illness

D5ea. Co-occurring Substance Use Disorders:
D5a. Co-Occurring Substance Use Disorders

Numbers Reported are:

D5b. No Co-Occurring Substance Use Disorders

Estimated

D5c. Unknown If Substance Use Disorder

Actual

D6ea. Veteran Status:
D6a.

Veteran

D6b.

Non-Veteran

D6c.

Unknown

Numbers Reported are:
Estimated
Actual

D7ea. Housing Status (at first contact):
D7a.

Outdoors (e.g., street, abandoned or
public building, automobile)

D7b. Short term shelter
D7c. Long term shelter
D7d.

Own or someone else's apartment,
room, or house

Numbers Reported are:
Estimated
Actual

D7e. Hotel, SRO, boarding house
Halfway house, residential treatment
program
Institution (psychiatric or other hospital,
D7g.
nursing home, etc.)
D7f.

D7h. Jail or correctional facility
D7i.

Other

D7j.

Unknown

D8ea. Length of time living outdoors or in short term shelter at first contact:
(Total sum for this item must be equal to D7a+D7b).
D8a.

Less than 2 days

D8b.

Two to 30 days

D8c.

31-90 days

D8d.

91 days to 1 year

D8e.

Over 1 year

D8f.

Unknown

Numbers Reported are:
Estimated
Actual

D8f1. Date data entry completed.
(mm/dd/yy)

Save / Update Data and Move to Next Page

.

M

PATH - 2008 Annual Provider Report Survey

file:///Users/user/Desktop/2009%20Survey%20Instrument/valid...

Next Step
Validate Your Entries
When you have finished entering data into the survey form please click on the button
below to run the validation program which will check that your entries meet the
requirements outlined in the instructions.
If you receive any errors you may go to the corresponding table(s) by clicking on the
buttons at the top of this page. Please make sure to click on "Save / Update Data and
Move to Next Page" buttons at the bottom of each page in order for modifications to be
sent to the database.
The PATH Program ID# 9000

I'm Finished, Validate My Entries
This may take a few minutes so please be patient.

1 of 1

1/9/09 2:08 PM