Form 1 Grantee Service Log

Attachment J3 – Service Log

OMB # XXXX-XXXX

Exp. XX/XXXX

SERVICE LOG

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

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.

S1. Did the youth in the TLP receive any of the following public supports either before enrolling in the TLP or while enrolled in the TLP or upon exit from the TLP? When did the youth receive this support? (Check all that apply.)

	S1a. Did youth receive this support?			S1b. If yes, when did the youth receive this support? (Check all that apply.)
				1. Before enrollment into TLP	2. During enrollment into TLP	3. At exit from TLP
	Yes	No	Don’t Know
HUD Section 8 or other permanent housing assistance
TANF or other welfare or non-disability income maintenance program
SSI or disability assistance
Medicaid
S-CHIP
Food Stamps/WIC
Childcare (non TANF)
Unemployment Insurance
Workforce development services (e.g. WAIT)
Non residential substance abuse treatment or mental health program
Individual Development Account (IDA)

S2. What kinds of services did the youth in the study access through the TLP? (Check all that apply.) Indicate whether these services where provided directly by the TLP or by another agency (through a referral).

	S2a. Service received?				S2b. Service provided by…
	Yes		No	Don’t Know	Your TLP		Another program or agency
Counseling/therapy/support groups (not family)
Counseling/therapy/support groups with family members
Peer-to-peer counseling
Physical/mental healthcare
Educational services/tutoring/GED prep.
Vocational training
Life-skills training/Learning to live independently
Counseling/education on safe sex/prevention/abstinence
Financial planning/money management assistance
Employment service/career planning/job-coaching
Substance abuse treatment
Parenting education/child care/pregnancy supports
Legal services
Family reunification supports/assistance
Mentoring
Organized recreational activities such as an after school or community athletic or arts program
Transitional, exit care, or aftercare planning
Voluntary participation in organized activities intended to help others or the community
Other services (Please specify)

S3. Is the youth pregnant or a teen parent?

Yes [ ] 01

No [ ] 02

S3a. If the youth is a parent, does his/her child live with them?

Yes [ ] 01

No [ ] 02

S3b. If yes, what kinds of support services were offered to help that youth parent effectively? (Check all that apply.)

Prenatal/birthing care [ ] 01

Post-natal care [ ] 02

Parenting education [ ] 03

Childcare [ ] 04

Help in accessing/paying for childcare [ ] 05

Help in accessing/providing child-support [ ] 06

Help in accessing WIC/food stamp [ ] 07

Other support particularly targeted towards parents (Please specify) [ ] 94

S4. What kinds of transitional/aftercare services were provided to the youth?
(Check all that apply.)

The youth received exit counseling [ ] 01

A written transitional, aftercare, post TLP or follow-up plan was developed with the youth [ ] 02

The youth received referrals to appropriate mainstream assistance programs [ ] 03

Future follow-up treatment services were prescribed and scheduled for the youth [ ] 04

The youth was placed in appropriate, permanent, stable housing (not a shelter) [ ] 05

The youth was transported to a temporary shelter that will provide age-appropriate safety, security and services, and necessary supervision [ ] 06

Other transitional/aftercare services (Please specify) [ ] 94

The youth refused or declined any and all of the above aftercare/exit care services
(including any listed as other) [ ] XX

5