HUD-92456 Semi-annual Performance Report

Semi-Annual Performance Report
Multifamily Housing
Service Coordinator Program

OMB Approval No. 2502-0447
(exp. 1/31/2007)

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

Public reporting burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency
may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. HUD collects
this information under Section 671 of the Housing and Community Development Act of 1992 and uses the information to evaluate the effectiveness and
efficiency of grant-funded activities. Providing this information is necessary to obtain benefits.

Instructions: See pages 3 and 4 for detailed instructions.
1. Contact Person (name and phone number including area code) 2. Source of funds for Service Coordinator (check one)

Grant/Contract - provide number (e.g., OK56CS94032)______________________
Residual Receipts
E-Mail Address:

Excess Income

Section 8 operating funds (project-based)

3. Project(s) served by the Service Coordinator(s) (List additional developments on a separate page)
Project Name

Project/FHA Number

Number of Units

4. Number of hours per week worked by the Service Coordinator
5. Resident Statistics
a. Total number of residents in all projects served
b. Estimated Age of residents
percent aged 18 to 61 (i.e., non-elderly people with disabilities)
percent aged 81 to 95

percent aged 62 to 80

percent over age 96

c. Estimated number of frail elderly residents (deficient in 3 or more Activities of Daily Living (ADLs))
d. Estimated number of at-risk elderly residents (deficient in 1 or 2 ADLs)
e. Total number of residents who utilized the SC during this reporting period
f. Total number of newly assigned residents assisted during this reporting period
6. Type of Service Coordination Performed
For each service, provide the number of residents who received that service. Identify only those residents who went through the SC to obtain these services.
Type of Service
Number of Residents
Type of Service
Number of Residents
Assessments

Home Management

Advocacy

Lease Education

Benefits/Entitlements/Insurance

Meals

Case Management

Mental Health Services

Conflict Resolution

Monitoring Services

Crisis Intervention/Support Counseling

Substance Abuse

Education/Employment

Transfer to Alternative Housing or Hospital

Family Support

Transportation

Health Care/Services

Other (specify)

Homemaker
7. Administrative Tasks
List the approximate percentage of time per month the SC performs these administrative tasks.
Documentation of resident files
Contact with outside service providers

%

Paperwork not related to a resident
%

Meetings with management staff

Name of person preparing this report

Signature

Title

Date (mm/dd/yyyy)

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%
%

form HUD-92456 (1/4/2007)

Please respond to the following items. Use additional pages if needed.
8. Educational / Wellness Programs
List the educational or wellness programs the SC developed and/or implemented for residents during this reporting period.

9. Fundraising
If you have engaged in any fundraising activities during this reporting period, please list them.

10. Professional Training
List the training programs the SC attended during this reporting period. Provide the name of the training program, its location, number of hours, and the
number of continuing education hours earned.

11. Resident Problems / Issues
Provide anecdotes (no more than two paragraphs each) describing two resident issues with which the SC was involved. Indicate whether the issue was
resolved during this reporting period and describe positive or negative outcomes.

12. Additional Information
Provide any other information relevant to the administration and performance of the SC Program. Provide any recommended "best practices" you have
found to be effective in providing service coordination and promoting independent living for the residents.

Are additional pages attached

Yes

No
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form HUD-92456 (1/4/2007)

Instructions for Completing Form HUD-92456
General:
All multifamily housing owners with Service Coordinators paid for
with any type of HUD funds must submit this Report. The Service
Coordinator or the Program contact person must complete the
form.
Submit one Report per Service Coordinator position, regardless of
funding source. If one Service Coordinator serves multiple developments or is funded through multiple funding sources, include all
relevant information on page 1.
Reporting Period: All Service Coordinators must submit this Report
according to the Federal Fiscal Year dates. The reporting periods
are October 1 through March 31 and April 1 through September 30.
Your Report is due to your local Field Office 30 days after the end of
the reporting period, i.e. April 30 and October 30, respectively.
Specific Instructions for each Item:
1. Contact Person. Enter the name, phone number, and email
address (if any) of the person most familiar with the information
provided on this form, who may be contacted by HUD for
questions regarding the form’s content.
2. Source of Funds for Service Coordinator. Check “Grant/
Contract” if you received a separate contract or grant for
funding the Service Coordinator since Fiscal Year 1992. Indicate the grant or contract number associated with this funding.
The middle four digits of this number must begin with “C93”,
“C94”, “CS”, "RS", or “HS”. Do not provide your project’s
Section 8 number (e.g. OHl2T871017)
Check “Residual Receipts” or "Excess Income" if your local
HUD office has approved the use of these funds to employ a
Service Coordinator. You may indicate this option if this is your
only source of funding or if you use residual receipts or excesss
income together with separate grant/contract funds.

5b. Estimated Age of Residents. Estimate the percentage of
total residents at all sites served by the Service Coordinator
who are within the age ranges.
5c and d. Estimated Number of frail elderly residents and
number of at-risk elderly residents. Estimate the number of
residents age 62 or older who are deficient in one, two, or
three or more Activities of Daily Living (ADLs). In making your
estimate, use HUD’s definition and list of ADLs found in
previously published Program Notices or application kits.
(ADL deficiencies, i.e. frailty or at-risk considerations, do not
apply to people with disabilities age 18-61.)
5e. Total number of residents who utilized the SC during this
reporting period. Indicate the total number of residents the
Service Coordinator assisted in any way during the six-month
reporting period. This may include a variety of tasks or
assistance provided. Do not count residents twice. Regardless of the amount of time spent assisting one resident, only
count that individual once.
5f. Total number of newly assigned residents assisted during
reporting period. Provide the number of residents you first
assisted during the reporting period.
6. Type of Service Coordination Performed. For each of the
listed services, provide the number of residents who received
that service. Identify only those residents who went through the
SC to obtain these services. For example, if a resident had
been receiving housekeeping services for a year prior to the
SC’s employment, do not include that resident in your “homemaker” count. If a resident’s son has arranged for Meals on
Wheels for that resident, do not include that resident in your
“meals” count. Only count those residents who the SC personally assisted in obtaining housekeeping or Meals on Wheels
services.

Check “Section 8 operating funds” if your local HUD office has
approved the Service Coordinator as an on-going permanent
expense in your project’s operating budget. If this is the case,
you will not be using either residual receipts, excess income, or
grant/contract funds.

Note: If a previously-employed SC helped residents to obtain any of
these services and a new SC has taken over during the current
reporting period, count all residents assisted by either SC.

3. Projects Served by the Service Coordinator. One grant/
contract may include funding for more than one project. List all
projects served by the grant/contract indicated in item #2, above.

Use your discretion in indicating the categories for the services
you coordinate. Choose the category you feel most appropriately represents these services.

If one Service Coordinator serves more than one project and is
funded by the residual receipts, excess income, or operating
budgets of those projects, list all projects assisted by the
Service Coordinator.

7. Administrative Tasks. List the approximate percentage of
time per month the SC performs these administrative tasks.

Include each project number (e.g. 042-EH406) and the number
of units in each project.
4. Number of hours per week worked by the Service Coordinator.
Indicate the total or average (if variable) number of hours
worked by the Service Coordinator per week at all sites.
5. Resident Statistics.
5a. Total Number of Resident. Provide the total number of all
residents in all projects served.

Please add any other services not included on this list either on
Page 1of this form or on an attached page.

Documentation of resident files Includes any notes you
make, forms completed, or other information inserted in resident files.
Contact with outside service providers. Include any activity
related to obtaining information about or advocating for affordable supportive services or assistance for residents. Such
activity may include telephone conversations, face-to-face
meetings, coalition or task force meetings, or working groups.
Paperwork not related to a resident. Include any reports
written for management staff, supervisors, or peers, or paperwork related to registering for training, arranging travel, or
purchasing supplies or equipment.

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form HUD-92456 (1/4/2007)

Meetings with management staff. Includes meeting with
project manager or administrator, contract supervisor or management staff, or any other related meeting.
8. Educational/Wellness Programs. List the educational or
wellness programs the SC developed and/or implemented for
residents during this reporting period. Provide the name or
topic of each program only and give the approximate number of
residents who attended. Examples of such programs are talks
on osteoporosis, nutrition, or accessibility issues for people
with disabilities, “brown bag” medication meetings with pharmacists, or remembrance groups.
9. Fundraising. List fundraising activities, if any, completed
during this reporting period. Provide the name or brief description of each activity, the amount of funds raised, and the
intended use of these funds.
10. Professional Training. List the training programs the SC
attended during this reporting period. Provide the following
information for each program attended:
o name of the training program,
o the location,
o the number of hours, and
o the number of continuing education hours earned.

11. Resident Problems/Issues. Provide anecdotes (no more
than two paragraphs each) describing two resident issues
with which the SC was involved. Indicate whether or not the
issue was resolved during this reporting period. Describe
positive and/or negative outcomes. The objective of this item
is to give readers of the report a description of the SC’s work
and the types of issues dealt with on a daily basis. Unresolved
situations will be viewed as examples of difficult problems or
circumstances and not as a negative reflection of the SC’s
efforts. Please be candid in your account, in order to give the
reader an accurate description of the SC’s work.
12. Additional Information. Provide any other information relevant to the administration and performance of the SC Program.
Provide any recommended “best practices” you have found to
be effective in providing service coordination and promoting
independent living for the residents. Examples of your “best
practices” will be essential in helping others develop SC programs and in supporting and obtaining funding. HUD staff
welcome any comments related to the SC Pr

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form HUD-92456 (1/4/2007)