VA Form 10-0508b Quarterly Grantee Performance Report

U.S. Department of Veterans Affairs

Supportive Services for Veteran Families (SSVF) Program

Quarterly Grantee Performance Report

Instructions: Please complete the following form and email, along with your Quarterly Financial Report (Attachment 1), to the VA SSVF Program Office at [email protected]. Please clearly mark any information that is confidential to individual participants.

Grantee Name:

SSVF Grant Amount:

Date of Report:

GENERAL

1. Describe any significant events (positive and negative) that occurred within your program during this quarter. Explain how these events will impact your performance.

2. Do you require additional assistance from the SSVF Program Office? If so, please specify the nature of the assistance required.

OUTREACH & SCREENING

3. Please list the types of locations / events (e.g., shelters, street, stand downs, housing courts, welfare offices, etc.) where your program has conducted outreach during this quarter.

4. Attach a copy of the participant screening form used this quarter if it has changed since the previous quarter.

5. Please list any types of organizations / entities from which you have received more than an estimated 5% of your referrals during this quarter.

6. How many ineligible individuals were screened this quarter? Describe generally how these situations were handled and the program(s) to which individuals were referred.

SUPPORTIVE SERVICES

7. During this quarter, which of the following supportive services were provided by your program (either directly or by referral)?

Type of Benefit/Service (See 38 CFR 62.33 for definitions of these services)*	Grantee/program provided benefit directly (Yes/No)	Grantee/program assisted participants in obtaining benefit through referrals to other organizations (Yes/No)
Health care services	Yes No	Yes No
Daily living services	Yes No	Yes No
Personal financial planning services	Yes No	Yes No
Transportation services	Yes No	Yes No
Income support services	Yes No	Yes No
Fiduciary and representative payee services	Yes No	Yes No
Legal services	Yes No	Yes No
Child care	Yes No	Yes No
Housing counseling, housing search	Yes No	Yes No
Other: __________________	Yes No	Yes No
Other: __________________	Yes No	Yes No
Other: __________________	Yes No	Yes No

8. List the three supportive services most requested by participants and describe how your program delivered those supportive services.

9. During this quarter, which of the following other supportive services were provided by your program? (see 38 CFR 62.33 and 38 CFR 62.34 for descriptions of these supportive services)

Rental Assistance	Child Care Financial Assistance
Utility-Fee Payment Assistance	Transportation
Security or Utility Deposit Assistance	Other: __________________
Moving Costs Assistance	Other: __________________
Emergency Supplies Assistance

PARTICIPANTS

10. Describe any issues that arose this quarter with respect to participant safety (e.g., domestic violence, suicide risk, etc.) and indicate how those issues were handled.

PROGRAM GOALS AND OUTCOMES

11. As this is a new initiative, VA is interested in learning about best practices in the field. Please describe an interesting/notable participant case from this quarter (describe the household composition, their needs, the services provided, and the outcomes).

12. Confirm that your program’s data for 100% of participants has been exported from HMIS and uploaded to the SSVF Data Repository not less than on a monthly basis. If not, please explain why.

SSVF GRANT AGREEMENT COMPLIANCE

13. Have you complied with all the terms of your supportive services grant agreement this quarter? If no, please explain.

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10-0508b

SVF PROGRAM NUMBER: ___-___-____

VA Form

July 2011