Form PD Interview PD Interview PD Interview

Attachment 1: Project Director Telephone Interview

OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX

Substance Abuse and Mental Health Services Administration (SAMHSA)

National Evaluation of SAMHSA’s Homeless Programs

Project Director Telephone Interview

Public Burden Statement: 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-XXXX.  Public reporting burden for this collection of information is estimated to average 3.5 hours per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

[PREPOPULATE A1 – A13]

A1. TI/SM (Application#):

A2. Grantee Agency Name:

A3. Project Name:

A4. Grantee Location: City:

State:

A5. Evaluation Extractor ID#:

A6. Date of document extraction:

A7. Interviewer ID#:

A8. Date of email (mm/dd/yy):

A9. Date of interview (mm/dd/yy):

A10: Respondent ID #:

A11. Role of respondent:

Project Director/Manager

Evaluator

Other, specify:

A12. Project’s SAMHSA Homeless Program:

Cooperative Agreements to Benefit Homeless Individuals (CABHI)

Grants for the Benefit of Homeless Individuals (GBHI), specify:

General Track

SSH Track

Services in Supportive Housing (SSH)

Projects for Assistance in Transition from Homelessness (PATH)

A13. Cohort Year (Year Grantee was funded):

2009

2011

2010

2012

___________________________________________________

INTERVIEWER TO PREPOPULATE THE FOLLOWING QUESTIONS: A1-A13, 1, 2, 3, 5, 5a, 6, 8, 8a, 9, 9a, 9b, 10, 11, 12, 14, 15, 15a, 16, 20, 21, 21a, 21b, 21c, 22, 23, 24, 25, 26, 27, 32, 34, 37, 40, 50, 57, 63, 64, 65, 65a, 65b, 66, 67, 68, 69.

Welcome—and thank you for taking the time to speak with us today!

As a CABHI/GBHI/SSH/PATH grantee, your knowledge and understanding of the CABHI/GBHI/SSH/PATH program and services are valuable. In your responses, consider the events that have occurred since the CABHI/GBHI/SSH/PATH project was awarded. If federal funding has ended, please think about the program while it was funded. There will be a few questions that are specific to those grantees who have ended their CABHI/GBHI/SSH/PATH funding.

Grantee Agency & Project Characteristics

1. Has Federal funding for your local CABHI/GBHI/SSH/PATH project ended? [PREPOPULATE]

___Yes ___No

SAMHSA Homeless Program(s) for which your grantee agency currently receives funding or has ever received funding: (check all that apply) [PREPOPULATE]

___ Cooperative Agreements to Benefit Homeless Individuals (CABHI) ___ Grants for the Benefit of Homeless Individuals (GBHI) ___ General Track ___ Chronic Homeless Track (2006 only) ___ SSH Track ___ Services in Supportive Housing (SSH) ___ Projects for Assistance in Transition from Homelessness (PATH)

The next questions address characteristics of the grantee agency.

3. What type of organization is your grantee agency? (check more than one, if appropriate)

[PREPOPULATE]

___ Social service agency

___ Drop-in center agency

___ Shelter

___ Case Management agency

___ Housing organization
___ Treatment provider (non-hospital stand alone clinic/agency/residence):

___Substance abuse treatment agency

___ Residential

___ Outpatient

___ Both

___ Mental health treatment agency

___ Residential

___ Outpatient

___ Both

___ Medical treatment

___ Hospital
___ Employment organization

___ Education organization
___ Veterans organization/administration
___ Criminal justice organization

___ Youth organization

___ HIV/AIDS service agency

___ Not a direct service provider (e.g., state/city government, SA/MH/Housing Authority, etc.); specify:_________________________

___ Other, specify:

4. Which single organization type best describes your grantee agency?

(check one)

___ Social service agency

___ Drop-in center agency

___ Shelter

___ Case Management agency

___ Housing organization
___ Treatment provider (non-hospital stand alone clinic/agency/residence):

___Substance abuse treatment agency

___ Residential

___ Outpatient

___ Both

___ Mental health treatment agency

___ Residential

___ Outpatient

___ Both

___ Medical treatment

___ Hospital
___ Employment organization

___ Education organization
___ Veterans organization/administration
___ Criminal justice organization

___ Youth organization

___ HIV/AIDS service agency

___ Not a direct service provider (e.g., state/city government, SA/MH/Housing Authority, etc.); specify:_________________________

___ Other, specify:

5. Is your grantee agency or organization: (check one)

[PREPOPULATE]

___ State or local government agency
___ For-profit company
___ Non-profit organization

5a. If not state or local government agency: (check all that apply)

[PREPOPULATE]

___ Faith-based organization

___ Research firm/organization

___ University

___ Other (specify):____________

6. Which of the following are dominant values¹ of the grantee agency? (check all that apply)

[PREPOPULATE]

___ Rehabilitative
___ Strengths based
___ Prescriptive
___ Confrontive
___ Supportive continuum
___ Other, specify:

7. Which of the following is the most important value of the grantee agency: (check one)

___ Rehabilitative
___ Strengths based
___ Prescriptive
___ Confrontive
___ Supportive continuum
___ Other, specify:

8. Does the grantee agency receive HUD funding?

[PREPOPULATE]

___ Yes

___ No

___ Don’t Know

8a. If yes, what is the annual amount provided?

[PREPOPULATE]

________ Annual amount provided by HUD

8b. What is the source of this HUD funding?

(check all that apply)

___ McKinney-Vento

___ Emergency Solutions Grant (ESG)

___ Continuum of Care Program

___ HUD-Veterans Affairs Supportive Housing Program (VASH)

___ Housing Opportunities for Persons with AIDS (HOPWA)

___ HUD Mainstream housing funds

___ Other, specify

9. Is the grantee agency formally part of a HUD Continuum of Care (CoC)?

[PREPOPULATE]

___ Yes

___ No

___ Don’t Know

[If No or Don’t Know, skip to Q10]

9a. What is the name of the CoC?

[PREPOPULATE]

__________________________________________________________

9b. What is the geographic area of this CoC?

[PREPOPULATE]

__________________________________________________________

9c. What organization(s) are the lead/primary agencies of the CoC?

__________________________________________________________

9d. How long has your agency been involved?

(check one)

___ less than 1 year

___ 1- 2 years

___ 2-3 years

___ 3 – 4 years

___ 5-10 years

___ 11 or more years

9e. Has your agency been involved since the CoC’s inception?

___Yes

___No

___Don’t Know

9f. What is your agency’s role in the CoC?

(check all that apply)

___Membership or attendance to committees, boards or other CoC groups and meetings

___Advocacy for a particular population

___As a provider of specific services

9g. Describe whether or how your CABHI/GBHI/ SSH/PATH project is related to or is influenced by your agency’s role in the CoC?

_________________________________________________________

10. What is the total project funding across all years for your CABHI/GBHI/ SSH/PATH project?

[PREPOPULATE]

$________ Project Funding from SAMHSA for CABHI

$________ Project Funding from SAMHSA for GBHI

$________ Project Funding from SAMHSA for SSH

$________ Project Funding from SAMHSA for PATH

(if your agency receives funding for multiple SAMHSA Homeless Program projects, please report only the funding for the project being dicussed during this interview)

11. What amount and percent of the total annual award budget for the CABHI/GBHI/SSH project goes toward evaluation annually?

SKIP for PATH grantees

[PREPOPULATE]

$_____________ = ____________% of total CABHI/GBHI/SSH award

If the amount varies by year, please provide the average across all years of the grant period.

12. Project funding from non-SAMHSA Homeless Program sources:

[PREPOPULATE]

Funding Source	Funding Year
	1	2	3	4	5
In-kind	$	$	$	$	$
SAMHSA (non-CABHI/GBHI/SSH/ PATH)	$	$	$	$	$
Federal (non-SAMHSA)	$	$	$	$	$
State	$	$	$	$	$
County	$	$	$	$	$
City	$	$	$	$	$
Medicaid	$	$	$	$	$
Other:	-----------	-----------	-----------	-----------	-----------
SPECIFY	$	$	$	$	$
SPECIFY	$	$	$	$	$

13. What is the approximate number of unduplicated clients served annually by the grantee agency (include all clients—CABHI/GBHI/ SSH/PATH and non- CABHI/GBHI/SSH/ PATH)? (Use most recent complete year)

________ Unduplicated number served per year

14. How many clients did your CABHI/GBHI/ SSH/PATH project serve in past project-funded years or do you plan to serve in the current and future project years (e.g., the SAMHSA approved target enrollment)?

For CABHI/GBHI/SSH grantees, what is the total for all funded years?

[PREPOPULATE]

CABHI Grantees:

______ Year 1

______ Year 2

______ Year 3

______ 3 year total for CABHI

GBHI & SSH Grantees:

______ Year 1

______ Year 2

______ Year 3

______ Year 4

______ Year 5

______ 5 year total for SSH and GBHI

PATH grantees, report the total number of clients the service providers you fund through PATH served or will serve in the fiscal year listed

______ 2010

______ 2011

______ 2012

______ 2013

14a. What percentage of the CABHI/ GBHI/SSH/PATH project clients receive SSI/SSD for a psychiatric disability?

___ None

___ 1% to 25%
___ 26% to 50%
___ 51% to 75%
___ 76% to 100%
___ Don’t Know

14b. What percentage of the CABHI/GBHI/SSH/PATH project clients receive SSI/SSD for a medical disability?

___ None

___ 1% to 25%
___ 26% to 50%
___ 51% to 75%
___ 76% to 100%
___ Don’t Know

14c. For what percentage of the CABHI/GBHI/SSH/ PATH project clients does the grantee agency serve as a representative payee for SSI/SSD?

___ None

___ 1% to 25%
___ 26% to 50%
___ 51% to 75%
___ 76% to 100%
___ Don’t Know

___ Not applicable

15. Which geographic area(s) does the CABHI/GBHI/SSH/ PATH project serve?

[PREPOPULATE]

Area: ________________________________

15a. Is the area you serve through the CABHI/GBHI/SSH/ PATH program: (check all that apply)

[PREPOPULATE]

___ Rural area
___ Suburban area (e.g., Urban Cluster)
___ Urban area

16. What types of staff expertise does your CABHI/GBHI/SSH/PATH project make available to project clients? List the name of each project staff member, then specify for each staff member: (1) area/s of licensure, (2) area/s of certification, (3) highest degree attained, (4) position in the CABHI/GBHI/SSH project, (5) primary location where the staff member provides services, and (6) the funded FTE and in-kind FTE. [PREPOPULATE]

Please include all in-kind and paid through the CABHI/GBHI/SSH/PATH grant staff.

Staff Name	Area of Licensure (list all that apply) 1. None 2. Medical - Psychiatry 3. Medical – Other Specialties 4. Physician Assistant 5. Nurse Practitioner 6. Registered Nurse 7. Clinical Psychologist 8. Counseling Psychologist 9. Marriage & Family Therapist 10. Mental Health Counseling 11. Substance Abuse Counseling 12. Social Worker 13. Education Specialist 14. Attorney/Esquire 15. Other specify:__	Area of Certification (list all that apply) 1. None 2. Integrated Treatment 3. Mental Health Counseling 4. Substance Abuse Counseling 5. Trauma Treatment 6. Domestic Violence 7. Peer Advocacy 8. Housing Specialist 9. Vocational Specialist 10. Education Specialist 11. Other, specify_____	Highest Degree 1. None 2. High School degree or GED 3. Associate’s degree 4. Bachelor’s degree 5. Master’s degree 6. Doctoral degree 7. Law degree 8. Medical degree	Position in CABHI/GBHI/SSH/PATH Project (list all that apply) 1. Diagnosis, Medication Treatment & Management 2.Health Specialist 3.Mental Health Counselor 4. Substance Abuse Counselor 5. Integrated Treatment Counselor 6. Trauma Specialist 7. Case Manager 8. Outreach Worker 9. Peer Specialist 10. Housing Specialist 11. Vocational Specialist 12. Educational Specialist 13. Project Director 14. Project Coordinator 15. Program Manager 16. Evaluator/Research/ Quality Improvement 17. Administrative/ Secretarial 18. Transportation (e.g. driver) 19. Other, specify:____	Primary Location for providing services 1. Street 2. Jail or prison 3. Hospital 4. Shelter 5. Drop-in center 6. Residential treatment facility 7. Halfway house 8. Three quarter housing (e.g., Oxford) 9. Safe Haven 10. Other Transitional housing (other than residential treatment, safe haven, halfway house) 11. Permanent housing 12. Outpatient treatment center 13. CABHI/GBHI/SSH project offices/grantee administration offices 14. Other, specify:____	Funded FTE (0 – 1)	In-Kind FTE (0 – 1)

Target Populations

17. How do your current target population criteria compare to the criteria you proposed in your initial application for the CABHI/GBHI/SSH/PATH grant? Please select the option that best describes your situation regarding your target population criteria.

1. Current and proposed criteria are identical; we have made no changes.

2. We expanded our criteria because under the proposed criteria we were unable to identify enough participants.

3. We tightened our criteria because under the proposed criteria we were had more eligible individuals than we had slots for.

4. We substantially changed our target population criteria because we changed the services and programs we are implementing; we selected new criteria to better fit our revised services and programs.

18. How do you select participants for CABHI/GBHI/SSH/PATH project activities? Please select the option that best describes your recruitment and enrollment process.

1. We recruit and enroll only participants who match all of our target population criteria.

2. We recruit participants who match target population criteria and give them priority enrollment, but if we have open slots we accept others who don’t match some criteria.

3. We do not focus our recruitment based on target population criteria but we give priority enrollment to those who meet the criteria.

4. We do not focus our recruitment based on target population criteria and enroll anyone who needs and will benefit from our services and programs.

19. Please provide an estimate of the percentage of your current CABHI/GBHI/SSH/PATH participants who meet each of the following levels of your current target population criteria. Your estimates should sum to 100%.

1. ___________% meet ALL of the criteria

2. ___________% meet SOME BUT NOT ALL of the criteria

3. ___________% meet NONE of the criteria

100% total

Within each of the following categories (i.e., Gender, Race/Ethnicity, Age, Behavioral Health and Treatment Status, Homeless Populations, Participants’ Primary Living Situation Before Entry into the Project, and Other Populations), indicate whether or not (1) the listed group is an inclusion criterion for enrollment/acceptance into your CABHI/GBHI/SSH/PATH project. Next, indicate if your project will (2) give priority to the group, but will also accept other groups. Finally, indicate if (3) the listed group has been or would be served, but is not an inclusion criterion and is not given priority admission to your project.

		1		2		3		4
20.	Within each of the following categories (e.g., gender, race/ethnicity, etc.), please tell us whether or not your CABHI/GBHI/SSH/PATH project: 1) has INCLUSION CRITERIA, that is, clients must meet these criteria/characteristics in order to be enrolled in the project (may include more than one group per category) 2) will give PRIORITY to one or more of the groups to receive project services – that is, the project will prioritize those groups for admission but will also accept others (may include more than one group per category) 3) SERVES one or more of the groups, but does not serve only that group or give them priority for admission (may include more than one group per category)	Inclusion Criteria: (Yes/No) [PRE-POPULATE]		Priority: (Yes/No) If YES, skip to Column 4 If NO, answer Column 3 [PRE-POPULATE]		Serve: (Yes/No/ NA) If YES, answer Column 4 If NO, skip to next row		If YES to 1, 2 or 3, please estimate the percentage of CABHI/ GBHI/SSH/ PATH project clients you serve in terms of this group.
	GENDER
a.	Female participants							------------
b.	Male participants							------------
c.	Transgender participants							------------
	RACE/ETHNICITY
d.	Black/African-American participants							------------
e.	White participants							------------
f.	Native-American/American Indian/Native Alaskan participants							------------
g.	Native Hawaiian or Pacific Island participants							------------
h.	Hispanic/Latino(a) participants							------------
i.	Asian participants							------------
j.	Priority for another race/ethnicity (specify):							------------
	AGE
k.	Adult (ages 18 and above) participants (i.e., general adult population, no youth)							------------
l.	Youth (e.g., under 18 years old) participants							------------
m.	Young adult (e.g., ages 18-21) participants							------------
n.	Older adult (e.g., 55 and over) participants							------------
	BEHAVIORAL HEALTH & TREATMENT STATUS
o.	Participants with mental disorders only
p.	Participants with substance abuse/dependence only
q.	Participants with co-occurring mental and substance use disorders
r.	Participants who are clean and sober
s.	Participants who are actively using alcohol or drugs (e.g., wet or damp)
t.	Participants who demonstrate stability of mental health symptoms
u.	Participants who are compliant with medication
v.	Participants who have reached a certain stage of change/readiness
w.	Participants in a mental health/substance abuse treatment program
x.	Participants who have reached a certain phase of treatment
y.	Participants who have completed treatment
z.	Other behavioral health or treatment status (specify):
	CLINICAL MENTAL HEALTH SEVERITY (percentage only)
aa.	Serious Mental Illness (SMI)or Serious and Persistent Mental Illness (SPMI) (e.g., Bipolar Disorder, Major Depressive Disorder, Schizophrenia and Schizoaffective Disorder)	--------		--------		--------
bb.	Mental Illness (Axis I disorders) other than SMI/SPMI	--------		--------		--------
cc.	Personality Disorders only	--------		--------		--------
dd.	Other (specify):	--------		--------		--------
	CLINICAL SUBSTANCE USE SEVERITY (percentage only)
ee.	Drug Dependence	--------		--------		--------
ff.	Alcohol Dependence	--------		--------		--------
gg.	Public Inebriate	--------		--------		--------
hh.	Drug Abuse	--------		--------		--------
ii.	Alcohol Abuse	--------		--------		--------
jj.	Drug use (not meeting criteria for Abuse/Dependence)	--------		--------		--------
kk.	Alcohol use (not meeting criteria for Abuse/Dependence)	--------		--------		--------
	HOMELESS POPULATIONS
ll.	At risk for becoming homeless (e.g., doubled up, coming out of jail or hospital, couch surfing, temporarily with friends/family) participants
mm.	Acutely (first time) homeless participants
nn.	Episodically homeless participants
oo.	Chronically homeless participants
	PARTICIPANTS’ PRIMARY LIVING SITUATION BEFORE ENTRY INTO THE PROJECT
pp.	Street
qq.	Shelter
rr.	Housed—transitional housing (e.g., time-limited, residential, sober housing, etc)
ss.	Housed—doubled up, couch surfing, living with others (friends and family)
tt.	Housed—current institutional to be released from jail/prison
uu.	Housed—current institutional, to be released from hospital
vv.	Housed—in own house, room or apartment (permanent housing, supportive or non-supportive)
ww.	Other living situation (specify):
	OTHER POPULATIONS
xx.	Participants experiencing high levels of housing mobility or instability
yy.	Participants who have a criminal justice record
zz.	Participants who do not have a criminal justice record
aaa.	Participants who are reentering from jail or prison
bbb.	Participants who are currently on probation/parole/court mandate
ccc.	Participants who are currently not on probation/parole/court mandate
ddd.	Participants who are chronic public inebriates
eee.	Participants who are veterans
fff.	Participants who are pregnant
ggg.	Participants with children/families
hhh.	Participants without children/families
iii.	Participants with a physical or developmental disability
jjj.	Participants living with HIV/AIDS
kkk.	Participants who have experienced domestic violence
lll.	Participants who are lesbian, gay, bisexual, transgender, or questioning (LGBTQ)
mmm.	Participants who are undocumented immigrants
nnn.	Other group of participants (specify):
ooo.	Other group of participants (specify):
ppp.	Other group of participants (specify):

Stakeholders/Partners

21. Does your CABHI/GBHI/SSH/PATH project hold formal partner/stakeholder meetings? [PREPOPULATE]

___Yes

___No [If NO, skip to Q22]

21a. If yes, do these formal meetings include stakeholders beyond project/subcontract staff? [PREPOPULATE]

___Yes

___No

21b. If yes, how frequently are stakeholder meetings held? [PREPOPULATE]

___Weekly

___Monthly

___Quarterly

___Annually

___Less frequently

21c. If yes, are formal minutes taken and disseminated? [PREPOPULATE]

___Yes

___No

[Q22 – 23 apply to CABHI, GBHI, and SSH. Note that for CABHI grantees, this is distinct from the Community Consortium Questions; please note who is on the Steering/Advisory Committee separately from who is on the Community Consortium]

22. Does your CABHI/GBHI/SSH project have a Steering Committee or an Advisory Committee that oversees your project? [PREPOPULATE]

___Yes

___No [If a CABHI project, skip to Q24; If GBHI or SSH, skip to Q28]

23. Please indicate who is on the Steering/Advisory Committee and if there is a signed Memorandum of Understanding (MOU). [PREPOPULATE]

Member Represents	Member of Steering/Advisory Committee [If NO, skip to next row]	Signed MOU available
State or local Public Housing Authority	Yes No	Yes No
Local mental health services provider organizations	Yes No	Yes No
Local substance abuse services provider organizations	Yes No	Yes No
Local primary care provider organizations	Yes No	Yes No
Local Continuum of Care	Yes No	Yes No
State Medicaid Office	Yes No	Yes No
State Mental Health Authority	Yes No	Yes No
State Substance Abuse Authority	Yes No	Yes No
Individuals who are homeless or have experienced homelessness and are recovering from mental and/or substance use disorders	Yes No	Yes No
SAMHSA Government Project Officer	Yes No	Yes No
Local housing providers	Yes No	Yes No
Other (specify): __________	Yes No	Yes No
Other (specify): __________	Yes No	Yes No

24. [QUESTION FOR CABHI PROJECTS ONLY] Is your CABHI project part of a Community Consortium? [PREPOPULATE]

___Yes

___No [If NO, skip to Q28]

25. [QUESTION FOR CABHI PROJECTS ONLY] Is your CABHI project the Local Lead Agency (LLA) for the Community Consortium? [PREPOPULATE]

___Yes

___No

26. [QUESTION FOR CABHI PROJECTS ONLY] Was the Community Consortium newly created for the grant or was it an existing State/Local Community Consortium? [PREPOPULATE]

___New Community Consortium created for grant

___An existing State/Local Community Consortium

27. [QUESTION FOR CABHI PROJECTS ONLY] Please indicate who comprises the Community Consortium and if there is a signed Memorandum of Understanding (MOU). [PREPOPULATE]

Member Represents	Member of Community Consortium [If NO, skip to next row]	Signed MOU available
State or local Public Housing Authority	Yes No	Yes No
Local mental health services provider organizations	Yes No	Yes No
Local substance abuse services provider organizations	Yes No	Yes No
Local primary care provider organizations	Yes No	Yes No
Local Continuum of Care	Yes No	Yes No
State Medicaid Office	Yes No	Yes No
State Mental Health Authority	Yes No	Yes No
State Substance Abuse Authority	Yes No	Yes No
Individuals who are homeless or have experienced homelessness and are recovering from mental and/or substance use disorders	Yes No	Yes No
Local housing providers	Yes No	Yes No
Other (specify): __________	Yes No	Yes No
Other (specify):_________	Yes No	Yes No

28. Prior to your local CABHI/GBHI/SSH/PATH project, how often did you collaborate with agencies or organizations in each of the following areas?

	Collaborations with…	Frequency of collaboration prior to CABHI/GBHI/SSH/PATH
		Never	Rarely	Occasionally	Frequently	Don’t know
a.	Social service providers
b.	State Medicaid office
c.	Substance abuse treatment providers
d.	State Substance Abuse Authority
e.	Mental health treatment providers
f.	State Mental Health Authority
g.	Housing providers
h.	State or local Housing Authority
i.	Local Continuum of Care
j.	Shelters
k.	Drop-in centers
l.	Medical (primary/specialized) care providers
m.	Education providers
n.	Employment or job training providers
o.	Veterans agencies
p.	Criminal justice agencies
q.	Peers/Consumers
r.	Family advocacy groups
s.	Policy-makers/legislators
t.	Research/evaluation

29. Since the start of your local CABHI/GBHI/SSH/PATH project, how often have you collaborated with agencies or organizations in each of the following areas?

	Collaborations with…	Frequency of collaboration since CABHI/GBHI/SSH/PATH
		Never	Rarely	Occasionally	Frequently	Don’t know
a.	Social service providers
b.	State Medicaid office
c.	Substance abuse treatment providers
d.	State Substance Abuse Authority
e.	Mental health treatment providers
f.	State Mental Health Authority
g.	Housing providers
h.	State or local Housing Authority
i.	Local Continuum of Care
j.	Shelters
k.	Drop-in centers
l.	Medical (primary/specialized) care providers
m.	Education providers
n.	Employment or job training providers
o.	Veterans agencies
p.	Criminal justice agencies
q.	Peers/Consumers
r.	Family advocacy groups
s.	Policy-makers/legislators
t.	Research/evaluation

[IF Q1 = YES, ANSWER 30; IF Q1 = NO, SKIP 30, GO TO 31]

30. Since Federal funding of your local CABHI/GBHI/SSH/PATH project stopped, how often have you collaborated with agencies or organizations in each of the following areas?

	Collaborations with…	Frequency of collaboration since CABHI/GBHI/SSH/PATH
		Never	Rarely	Occasionally	Frequently	Don’t know
a.	Social service providers
b.	State Medicaid office
c.	Substance abuse treatment providers
d.	State Substance Abuse Authority
e.	Mental health treatment providers
f.	State Mental Health Authority
g.	Housing providers
h.	State or local Housing Authority
i.	Local Continuum of Care
j.	Shelters
k.	Drop-in centers
l.	Medical (primary/specialized) care providers
m.	Education providers
n.	Employment or job training providers
o.	Veterans agencies
p.	Criminal justice agencies
q.	Peers/Consumers
r.	Family advocacy groups
s.	Policy-makers/legislators
t.	Research/evaluation

31. Since the start of your local CABHI/GBHI/SSH/PATH project, how effective have your collaborations been with agencies or organizations in each of the following areas? That is, how effective have your collaborations been in helping your local CABHI/GBHI/SSH/PATH project achieve its intended outcomes?

	Collaborations with…	Effectiveness of collaboration in helping achieve outcomes
		Not effective	Somewhat effective	Very effective	Don’t know	N/A
a.	Social service providers
b.	State Medicaid office
c.	Substance abuse treatment providers
d.	State Substance Abuse Authority
e.	Mental health treatment providers
f.	State Mental Health Authority
g.	Housing providers
h.	State or local Housing Authority
i.	Local Continuum of Care
j.	Shelters
k.	Drop-in centers
l.	Medical (primary/specialized) care providers
m.	Education providers
n.	Employment or job training providers
o.	Veterans agencies
p.	Criminal justice agencies
q.	Peers/Consumers
r.	Family advocacy groups
s.	Policy-makers/legislators
t.	Research/evaluation

32. We would like to know about the relationship between your agency and key partners (including other agencies, government bodies, communities, etc.) in your CABHI/GBHI/SSH/PATH project that support various aspects of your project, including implementation, community integration of the project, sustainability, etc. Include formal and informal partners who have a clear role in your CABHI/GBHI/SSH/PATH project; note that a clear role does not have to mean direct provision of services, it may also include participating on advisory boards, providing general advocacy, funders, state legislators, etc.

Please provide (A) the name of each partner/stakeholder, (B) if the partner/stakeholder is funded by HUD, (C) the type of service(s) the partner/stakeholder provides for your CABHI/GBHI/SSH/PATH project, (D) the partner/stakeholder’s organization type, (E) if your relationship was in effect BEFORE your CABHI/GBHI/SSH/PATH project was funded, (F) if your relationship has been in effect DURING your CABHI/GBHI/SSH/PATH project, and (G) the type of agreement you have with the partner/stakeholder, if any,

FOR GBHI AND SSH PROJECTS ONLY, please indicate if (H) the partner/stakeholder participates in advisory board and/or stakeholder meetings with your project.

FOR CABHI PROJECTS ONLY, please indicate if (I) the partner/stakeholder is a part of your project’s steering committee and (J) if the partner/stakeholder is a part of your project’s Community Consortium.

[PREPOPULATE TABLE]

A	B	C	D	E	F	G	H	I	J
Partner /Stakeholder Name	HUD Funded (Yes/No/ Unknown)	Type of Service(s) Partner Provides to the CABHI/GBHI/SSH/PATH project (list all that apply)	Type of Organization/Stakeholder (list all that apply)	Was this partnership in effect BEFORE this CABHI/ GBHI/SSH/ PATH grant was funded? (Yes/No)	Partnership in effect DURING this CABHI/ GBHI/ SSH/PATH project? (Yes/No)	Type of agreement: (list all that apply) 0) None 1) Letter of Support 2 )MOA/MOU 3) Subcontract	GBHI and SSH ONLY: Participates in Advisory Board/ Stakeholder Meetings (Yes/No)	CABHI ONLY: On Steering Committee (Yes/No)	CABHI ONLY: Part of Community Consortium (Yes/No)

Note for colum C: Types of Service: Housing (1), Substance abuse treatment (2), Mental health treatment (3), Integrated treatment (4), Medical treatment (5), Detox (6), HIV specific services (7), Case management (8), Peer support/services (9), Family support/counseling (10), Benefits assistance (11), Employment/vocational training (12), Education (13), Other Wraparound, specify:____ (14), Evaluation/Research (15), TA/Program Training (16), Referral Source (17)

Not a direct service provider, SPECIFY: 18. Advocacy, 19. Policymaker, 20. Funder, 21. Advisory, Other, specify (22)

Note for column D: Types of Organization: Social services (1), Substance abuse treatment provider (2), Mental health treatment provider (3), Housing provider (4), Shelter (5), Medical treatment provider (6), Education (7), Employment/job training (8), Veterans agency (9), Criminal justice agency (10), Consumer/family (11), Policy/Legislator (12), Evaluation/Research (13), Case management (14), HIV/AIDS Service agency (15), Funder (e.g., city/state/federal/foundation) (16), Advocacy (17), Advisory (18), TA/Training (19), Other, specify (20)

Services

33. To what extent is each of the following types of services provided to CABHI/GBHI/SSH/PATH project clients: directly by the grantee and paid by CABHI/GBHI/SSH/PATH project funds, by the grantee not paid by CABHI/GBHI/SSH/PATH project funds (in-kind), by other organizations paid by CABHI/GBHI/SSH/PATH funds, or through referral to other organizations not paid with CABHI/GBHI/SSH/PATH funds? For each cell, select 1 – 5 as follows:

1 – None or almost none (i.e., 0-5%)

2 – Very little (i.e., 6-25%)

3 – Some (i.e., 26-74%)

4 – Most (i.e., 75-94%)

5 – All or almost all (i.e., 95-100%)

	Provided directly by grantee to CABHI/GBHI/SSH/ PATH clients paid by CSAT/CMHS project funds	Provided by grantee to CABHI/GBHI/SSH/ PATH clients NOT paid by CSAT/CMHS project funds (in-kind)	Provided to CABHI/GBHI/SSH/ PATH clients by other organizations, paid by the grantee with CSAT/CMHS project funds	Provided to CABHI/GBHI/SSH/ PATH clients by other organizations through referral from grantee, no payment from grantee
Outreach & recruitment	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5
Case management (e.g., make appointments, provide referrals/linkages, monitor service delivery, etc)	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5
Substance abuse & mental health treatment	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5
Housing support services (e.g., complete housing applications, prepare for housing interview, contact landlords, etc)	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5
Housing	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5
Wraparound services (e.g., educational/vocational services, transportation, assistance in acquiring benefits, daily living skills, etc)	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5

34. The following questions address the types of services that are provided to clients by the CABHI/GBHI/SSH/PATH project. For each (A) listed service, please indicate:

(B) If the service is being provided to CABHI/GBHI/SSH/PATH project clients either directly by the grantee agency [or PATH provider] or through referral. If no, SKIP to the next service row.

(C) If YES, indicate the percentage of CABHI/GBHI/SSH/PATH project clients who have received the service in the past 6 months. If no project clients (0%) received the service, SKIP to the next service row.

(D) If 1% or more of project clients received the service, indicate if the grantee [or PATH provider] directly provides the service, the grantee [or PATH provider] pays for someone else (another agency/organization) to provide it, a partner directly provides the service without a referral from the grantee, or the client is referred to the service but no payment is given to provide the service. If the grantee [or PATH provider] makes a referral only, SKIP to the next service row.

(E) If the service is provided directly by the grantee, indicate the primary location/s where the service is provided (use the Setting Codes).

(F) If the grantee pays for someone else to provide the service, indicate the primary location/s where the service is provided (use the Setting Codes).

(G) If the service is provided directly by a partner without a referral from the grantee, indicate the primary location/s where the service is provided (use the Setting Codes).

(H) & (I) If the service is provided directly by the grantee, the grantee pays for someone else to provide it, or it is provided directly by a partner without a referral, indicate how the service is paid for and the length of time the clients may receive the service.

(I) If the service is provided directly by the grantee, indicate if the grantee [or PATH provider] provided this service prior to receiving CABHI/GBHI/SSH/PATH funding?

[PREPOPULATE]

Setting codes: (check all that apply)

1. Street

2. Jail or prison

3. Hospital

4. Shelter

5. Drop-in center

6. Residential treatment facility

7. Halfway house

8. Three quarter housing (e.g., Oxford)

9. Safe Haven

10. Other Transitional housing (other than residential treatment, safe haven, halfway house)

11. Permanent housing

12. Outpatient treatment center

13. CABHI/GBHI/SSH project offices/grantee administration offices

14. Other (specify)

A

B

C

D

E

F

G

H

I

J

NAME OF SERVICE

Provided to CABHI/ GBHI/SSH/ PATH project clients either directly or by referral? YES/NO [IF NO, skip to next service row] [PREPOPULATE]

What percentage of your project’s clients received the service during the past 6 months? 0) 0% [if 0, skip to next service row] 1) 1-25% 2) 26-50% 3) 51-75% 4) 76-100%

How is the service provided? (list all that apply) 1. Grantee [or PATH provider] provides it directly 2. Grantee pays for someone else to provide it 3. Partner provides it directly without referral 4. Grantee makes a referral but does not pay [If 4 ONLY, skip to the next service row] [PREPOPULATE]

If provided directly by grantee [or PATH provider], Where is the service provided (note the primary location/s)? [USE SETTING CODES ABOVE] [PREPOPULATE]

If grantee [or PATH provider] pays for someone else to provide, Where is the service provided (note the primary location/s)? [USE SETTING CODES ABOVE] [PREPOPULATE]

If provided directly by partner without referral, Where is the service provided (note the primary location/s)? [USE SETTING CODES ABOVE] [PREPOPULATE]

If provided directly by grantee, grantee pays for someone else to provide, or partner directly provides, How is the service paid for? (list all that apply) 1. CABHI/GBHI/ SSH/PATH grant funds 2. In-kind by grantee [PATH provider] 3. In-kind by partner agency 4. Medicaid/ Medicare 5. Client’s private insurance 6. Out-of-pocket by client UNKNOWN [PREPOPULATE]

If provided directly by grantee, grantee pays for someone else to provide, or partner directly provides, What is the time limit for how long a client may receive the service? 1. No time limit 2. Less than 6 months 3. 6 months – less than 12 months 4. 12 months – 24 months 5. Time limit length unknown [PREPOPULATE]

If provided directly by grantee [or PATH provider], was this service provided prior to receiving CABHI/GBHI/ SSH/PATH funding? YES/NO

Outreach, Engagement & Recruitment

SKIP

ANY SCREENING or ASSESSMENT (if known, specify and check all that apply):

SKIP

SKIP

Mental Disorders

Substance Use (abuse or dependence)

Co-Occurring Substance Use & Mental Disorders

Trauma

Other, specify: _________

TREATMENT SERVICES

ANY SUBSTANCE ABUSE (SA) TREATMENT (if known, specify and check all that apply):

SA outpatient counseling (if known, specify and check all that apply):

SKIP

SA group outpatient counseling

SKIP

SA individual outpatient counseling

SKIP

SA residential treatment (group & individual)

SKIP

SA inpatient (hospital) treatment

SKIP

SA Pharmacotherapy (e.g., Methadone/ Buprenorphine)

SKIP

Outpatient Detox

SKIP

Residential Detox

SKIP

Relapse prevention

SKIP

ANY MENTAL HEALTH (MH) TREATMENT (if known, specify and check all that apply):

MH outpatient counseling (if known, specify and check all that apply):

SKIP

MH group outpatient counseling

SKIP

MH individual outpatient counseling

SKIP

MH partial hospitalization/day treatment

SKIP

MH residential treatment (group & individual)

SKIP

Inpatient psychiatric hospitalization

SKIP

MH Pharmacotherapy (e.g., anti-depressants, anti-psychotics, anti-anxiety medications, etc)

SKIP

Family Treatment

Trauma/PTSD treatment services

ANY INTEGRATED MENTAL HEALTH AND SUBSTANCE ABUSE (COD) TREATMENT (if known, specify and check all that apply):

COD outpatient counseling (if known, specify and check all that apply):

SKIP

COD group outpatient counseling

SKIP

COD individual outpatient counseling

SKIP

COD residential treatment (group & individual)

SKIP

Crisis care (e.g., 24 hour crisis response service)

WRAPAROUND SERVICES

Case management

Discharge planning

Aftercare

Drug testing

ANY SELF-HELP OR PEER SERVICES (if known, specify and check all that apply):

12-step self-help groups (e.g., AA/NA, Al-Anon, Double Trouble, etc)

SKIP

Non-12-step self-help groups

SKIP

Peer-to-peer mental health and/or substance abuse counseling (if known, specify and check all that apply):

SKIP

Peer Mentoring

SKIP

Drop-in/Social Club

SKIP

ANY MEDICAL/ HEALTH CARE SERVICES (if known, specify and check all that apply):

SKIP

General medical treatment

Specialized medical care for women

Dental Care

HIV/AIDS testing, prevention education & treatment

HEP C testing/education/ treatment

Other STD testing/treatment

Health & Wellness (e.g., health/wellness education, group exercise activities, nutrition education, etc)

ANY VOCATIONAL OR EMPLOYMENT SERVICES (if known, specify and check all that apply):

Job readiness/skills

SKIP

Job placement

SKIP

On-site employment

SKIP

Job retention services – support, coaching, etc

SKIP

Other Vocational/ Employment services (specify): ________________

SKIP

Education/GED program

ANY BENEFITS OR INSURANCE SERVICES (if known, specify and check all that apply):

SKIP

Medical insurance applications (including Medicaid/Medicare)

Other benefits application (SSI/SSD, food stamps, etc)

Assistance in getting identification

SKIP

ANY LEGAL ASSISTANCE (if known, specify and check all that apply):

Civil (e.g., custody/ visitation/ termination of parental rights, landlord disputes, credit history, etc)

SKIP

Criminal (e.g., charges, warrants, violations, etc)

SKIP

ANY HOUSING SERVICES (if known, specify and check all that apply):

Housing application assistance

SKIP

Housing readiness training

SKIP

Housing placement

SKIP

Housing supports post placement (e.g., managing household, time management, landlord disputes, budgeting, etc)

SKIP

Material Support (if known, specify and check all that apply):

SKIP

Food/food pantry

SKIP

Furniture

SKIP

Clothing

SKIP

Financial assistance for security deposits

SKIP

Other, specify: ____________

SKIP

Independent living skills/Daily living skills training (e.g., food shopping, cleaning, hygiene, money management, etc)

ANY SUPPORT SERVICES FOR FAMILIES (non-treatment family services) (if known, specify and check all that apply)

Parenting skills/education

SKIP

Childcare

SKIP

Support groups

SKIP

Domestic violence services

SKIP

Family advocacy

SKIP

Family reunification

SKIP

Assistance with accessing services for children

SKIP

Transportation

Social & Recreational Activities

Other, specify:

Other, specify:

Other, specify:

As reported in Q34, if integrated mental health and substance abuse treatment is provided directly by the grantee, the grantee pays for someone else to provide it,OR a partner directly provides it, answer Q35; If integrated mental health and substance abuse treatment is not provided or provided only through referral, SKIP to Q36.

35. Please tell us about the integrated mental health and substance abuse treatment you provide to CABHI/GBHI/SSH/PATH clients. These questions apply only to clients who are receiving integrated mental health and substance abuse treatment.

a. Clients are screened for both mental health and substance use problems	Yes No
b. Clients are assessed for both mental health diagnosis and substance use diagnosis and accompanying treatment needs by a licensed professional	Yes No
c. Clients receive mental health services on-site and are referred to substance abuse treatment services off-site	Yes No
d. Clients receive substance abuse treatment services on-site and are referred for mental health services, including medication management, off-site	Yes No
e. Clients receive mental health and substance abuse treatment at the same site	Yes No
f. Clients receive on-site group sessions specifically designed to address both mental health and substance use problems (e.g., dual diagnosis groups)	Yes No
g. Staff include mental health professionals who provide mental health treatment and substance abuse professionals who provide substance abuse treatment	Yes No
h. Staff are cross-trained in substance abuse and mental health treatment.	Yes No
i. Clients must be in recovery prior to beginning mental health treatment.	Yes No
j. Mental health and substance abuse treatment staff serve on the same team and collaborate on treatment plan	Yes No
k. Clients must be stable mentally before beginning substance abuse treatment	Yes No

36. Please tell us about the role of client choice in treatment.

a. In which ways does your agency accommodate client choice with regard to treatment for your CABHI/GBHI/SSH/PATH project clients? (check all that apply)	___ Type of treatment (e.g., substance abuse, trauma, integrated treatment, etc.) ___ Types of medication prescribed ___ Modality of treatment (e.g., group vs.individual) ___ Treatment setting (e.g., residential, outpatient, continuing day treatment, at housing) ___ Length of treatment ___ Other, specify: ________________
b. Treatment assignments are determined by: (check all that apply)	___ Client choice ___ The treatment program ___ Criminal justice record ___ Probation/parole/court mandate considerations ___ Being clean and sober ___ Reached a certain phase of treatment ___ Stability of mental health symptoms ___ Stage of change ___ Other clinical determinations, specify:_____ ___ Psychiatric advanced directives ___ Other, specify: ______________

Evidence Based Practices/Promising or Best Practices

37. Given the scope of the CABHI/GBHI/SSH projects, there is a range of Evidence-Based Practices (EBPs) and promising practices that could be implemented. Some projects may be implementing clinical EBP’s like the Modified Therapeutic Community, Integrated Dual Disorders Treatment, or the Trauma Recovery and Empowerment Model (TREM). Other programs may be focused on implementing non-clinical EBP’s (including case management, other wraparound, & housing) like Strengths-Based Case Management, Supported Employment, or Permanent Supportive Housing. Some projects are focused on implementing both clinical and non-clinical EBP’s.

We are interested in the implementation of EBPs for your CABHI/GBHI/SSH project for CABHI/GBHI/SSH clients. Please indicate (A) the status of implementation for each EBP proposed for the CABHI/GBHI/SSH project. If the EBP was implemented or is currently being implemented during the grant project, please indicate (B) the percentage of project clients that received the practice in the past 6 months, (C) whether it was provided by the grantee agency or through referral/linkage to another agency and if CABHI/GBHI/SSH funds were used to pay for the practice, and (D) where the practice is provided. If CABHI/GBHI/SSH grant funding has ended, please indicate (E) whether you are still implementing the EBP.

		A	B	C	D	E
EBP/Promising or Best Practice Name	Proposed for implementation in the grant application? YES/NO [PREPOPULATE]	Status of EBP implementation for the CABHI/GBHI/SSH project: 1. Not planned and not implemented 2. Planned but decided not to implement 3. Planned but not yet implemented 4. Previously implemented as part of the grant project, but stopped 5. Currently implementing [IF 1, 2, or 3, SKIP to next EBP]	If implemented for the grant project, What % of project participants received the practice during the past 6 months? 1. 0 % [IF 0, skip to next row] 2. 1 – 25% 3. 26 – 50% 4. 51 – 75% 5. 76 – 100%	If implemented for the grant project, How was it provided (by grantee agency, through linkage/ referral to another agency) and was it paid for with CABHI/GBHI/SSH grant funds? (check all that apply) 1. Provided by grantee, paid by grant 2. Provided by grantee, in-kind 3. Provided through linkage/referral, paid by grant 4. Provided through linkage/referral, in-kind	If implemented for the grant project, Where is/was this service provided? (use setting codes)	If CABHI/ GBHI/SSH grant funding has ended, are you still implementing the EBP? YES/NO
CLINICAL EBPs/PROMISING OR BEST PRACTICES
Adolescent Community Reinforcement Approach (ACRA)
Assertive Community Treatment (ACT)
Assertive Continuing Care
Celebrating Families
Cognitive Behavioral Therapy (CBT)
Cognitive Processing
Contingency Management
Criminal Justice – if yes, which practice: _____TIP 44 Other SPECIFY:____________
Dialectical Behavioral Therapy (DBT)
Eye Movement Desensitization & Reprocessing (EMDR)
Family Psychoeducation
Harm Reduction Therapy
Helping Women Recover
Illness Management & Recovery (IMR)
Integrated Treatment – if yes, which practice: ___IDDT/Integrated Treatment for Co-Occurring Disorders ___Dual Recovery Therapy ___TIP 42 Other, SPECIFY _______
Intensive Outpatient Program (IOP)
Living in Balance
Matrix Model
Medication-Assisted Treatment for Substance Abuse Disorders
Medication management – Mental Health (e.g., MedMAP, MedTEAM) SPECIFY:___________________
Modified Therapeutic Community for Persons w/Co-Occurring (MTC)
Moral Reconation Therapy
Motivational Enhancement Therapy (MET)
Motivational Interviewing (MI) (includes TIP 35) SPECIFY:___________________
Relapse Prevention Therapy
Sanctuary Model
Screening, Brief Intervention & Referral into Treatment (SBIRT)
Seeking Safety
Solution Focused Therapy
Transtheoretical Model (TTM)
Trauma Affect Regulation Therapy
Trauma Focused CBT
Trauma Recovery & Empowerment Model (TREM)
Twelve Step Facilitation
Voices
Wellness Recovery Action Plan (WRAP)
Wellness Self-Management (WSM)
OTHER TIP’s (Clinical) NOT LISTED ABOVE	---------------	---------------	---------------	---------------	---------------	---------------
Detoxification (includes the following TIP’s: 19, 45) SPECIFY: __________________
Medication– Substance Abuse (includes the following TIP’s: 20, 22, 28, 40, 43) SPECIFY:___________________
Screening and Assessment (includes the following TIP’s: 3, 6, 7, 9, 10, 11, 31) SPECIFY:___________________
Substance abuse treatment (includes the following TIP’s: 2, 4, 8, 24, 26, 29, 32, 33, 34, 37, 39, 41, 46, 47, 48, 49, 50) SPECIFY:__________________
Trauma treatment (includes the following TIP’s: 16, 25, 36) SPECIFY:___________________
Other (specify):
Other (specify):
Other (specify):
NON-CLINICAL EBPs/PROMISING OR BEST PRACTICES
A Woman’s Path to Recovery
Critical Time Intervention (CTI)
Customized Employment Supports
Double Trouble in Recovery
Housing First
Intensive Case Management (ICM)
Medicine Wheel
Peer Support/Mentoring
Permanent Supportive Housing
Project RESPECT
SISTA
SSI/SSDI Outreach, Access and Recovery (SOAR)
Story Telling/Telling Stories
Street Smart
Strengthening Families
Strengths-Based Case Management (SBCM)
Supported Education
Supported Employment
Sweat Lodge Ceremonies
Talking Circles
Other (specify):
Other (specify):
Other (specify):

Note for column D: Setting Codes: 1. Street, 2. Jail or prison, 3. Hospital , 4. Shelter, 5. Drop-in center, 6. Residential treatment facility, 7. Halfway house

8. Three quarter housing (e.g., Oxford), 9. Safe Haven, 10. Other Transitional housing (other than residential treatment, safe haven, halfway house), 11. Permanent housing,

12. Outpatient treatment center, 13. CABHI/GBHI/SSH project offices/grantee administration offices, 14. Other (specify)

38. What are the top three primary EBPs (Clinical and/or Non-Clinical) to be implemented with CABHI/GBHI/SSH clients? Primary EBPs are defined as those received by the largest number of clients. If there is one primary EBP being implemented, list that EBP only (do not list additional EBPs if they are not considered primary). If there is more than one primary EBP being used for main implementation, note up to 3 practices total.

1.
2.
3.

39. For each of the primary EBPs identified above in Q38, please tell us more about where you are with regard to implementation:

	EBP#1:	EBP#2:	EBP#3:
39a. Which of the following best describes the current stage of implementation of this EBP for program participants?	Preparation (e.g., hiring staff, conducting initial training, creating new operation polices & procedures, developing/finalizing strategic implementation plan) Early Implementation (e.g., referrals, screening & assessments occurring, services are underway) Full Implementation (e.g., staff skillful in service delivery, new policies & procedures are routine, practice is fully integrated into agency/program) Sustainability (e.g., fully implementing, sustainability plan developed & underway, continuous staff training & funding secured for future, outcomes used for program improvement) Other, specify:_________	Preparation (e.g., hiring staff, conducting initial training, creating new operation polices & procedures, developing/finalizing strategic implementation plan) Early Implementation (e.g., referrals, screening & assessments occurring, services are underway) Full Implementation (e.g., staff skillful in service delivery, new policies & procedures are routine, practice is fully integrated into agency/program) Sustainability (e.g., fully implementing, sustainability plan developed & underway, continuous staff training & funding secured for future, outcomes used for program improvement) Other, specify:_________	Preparation (e.g., hiring staff, conducting initial training, creating new operation polices & procedures, developing/finalizing strategic implementation plan) Early Implementation (e.g., referrals, screening & assessments occurring, services are underway) Full Implementation (e.g., staff skillful in service delivery, new policies & procedures are routine, practice is fully integrated into agency/program) Sustainability (e.g., fully implementing, sustainability plan developed & underway, continuous staff training & funding secured for future, outcomes used for program improvement) Other, specify:_________
39b. How is fidelity to this EBP monitored? (check all that apply)	Direct observation Tape/video recorded sessions/groups Focus groups or interviews with program participants Key informant interviews Document review Regular use of a standardized fidelity tool/checklist, specify:­­­­________ Other, specify:_________ We do not monitor fidelity to this EBP [If selected, SKIP to 39h]	Direct observation Tape/video recorded sessions/groups Focus groups or interviews with program participants Key informant interviews Document review Regular use of a standardized fidelity tool/checklist, specify:­­­­________ Other, specify:_________ We do not monitor fidelity to this EBP [If selected, SKIP to 39h]	Direct observation Tape/video recorded sessions/groups Focus groups or interviews with program participants Key informant interviews Document review Regular use of a standardized fidelity tool/checklist, specify:­­­­________ Other, specify:_________ We do not monitor fidelity to this EBP [If selected, SKIP to 39h]
39c. How often is fidelity data collected/assessed for this EBP? [If not monitoring fidelity, SKIP]	Every six months Annually Ongoing Other, specify:____________	Every six months Annually Ongoing Other, specify:____________	Every six months Annually Ongoing Other, specify:____________
39d. Who conducts fidelity assessments for this EBP? (check all that apply) [If not monitoring fidelity, SKIP]	CABHI/GBHI/SSH Project Evaluator Staff internal to provider agency Staff external to provider agency Consultant Other, specify:____________	CABHI/GBHI/SSH Project Evaluator Staff internal to provider agency Staff external to provider agency Consultant Other, specify:___________	CABHI/GBHI/SSH Project Evaluator Staff internal to provider agency Staff external to provider agency Consultant Other, specify:___________
39e. To what degree has this EBP been implemented to fidelity so far? [If not monitoring fidelity, SKIP]	Low – Less than 50% of components implemented to fidelity Moderate 50-80% of components implemented to fidelity High – 80-100% of components implemented to fidelity	Low – Less than 50% of components implemented to fidelity Moderate 50-80% of components implemented to fidelity High – 80-100% of components implemented to fidelity	Low – Less than 50% of components implemented to fidelity Moderate 50-80% of components implemented to fidelity High – 80-100% of components implemented to fidelity
39f. If implemented with moderate to low fidelity so far, why? [If not monitoring fidelity, SKIP]	All components planned but not yet fully implemented [Go to 39h] Some components were purposefully modified [Go to 39g] 39g. If modified, describe how and why (e.g., why certain components were not implemented or revised or new components added)      	All components planned but not yet fully implemented [Go to 39h] Some components were purposefully modified [Go to 39g] 39g. If modified, describe how and why (e.g., why certain components were not implemented or revised or new components added)      	All components planned but not yet fully implemented [Go to 39h] Some components were purposefully modified [Go to 39g] 39g. If modified, describe how and why (e.g., why certain components were not implemented or revised or new components added)      
39h. What factors have served as barriers to implementation of this EBP (i.e. have hindered successful implementation) (check all that apply)	Lack of clear strategic plan for implementing the EBP Inadequate financing for the EBP Limited staff time/staff resources for EBP implementation Lack of on-going training, supervision, and consultation on the EBP Lack of positive practitioner attitudes toward the EBP Lack of prior experience with this EBP Lack of prior experience with other EBPs State or local policy/regulations Grantee or partner agency policies or practices Lack of support for implementation from key leaders at grantee or partner agency Lack of support for implementation from key external stakeholders Other, specify­­­­_______ Other, specify­­­­_______ None	Lack of clear strategic plan for implementing the EBP Inadequate financing for the EBP Limited staff time/staff resources for EBP implementation Lack of on-going training, supervision, and consultation on the EBP Lack of positive practitioner attitudes toward the EBP Lack of prior experience with this EBP Lack of prior experience with other EBPs State or local policy/regulations Grantee or partner agency policies or practices Lack of support for implementation from key leaders at grantee or partner agency Lack of support for implementation from key external stakeholders Other, specify­­­­_______ Other, specify­­­­_______ None	Lack of clear strategic plan for implementing the EBP Inadequate financing for the EBP Limited staff time/staff resources for EBP implementation Lack of on-going training, supervision, and consultation on the EBP Lack of positive practitioner attitudes toward the EBP Lack of prior experience with this EBP Lack of prior experience with other EBPs State or local policy/regulations Grantee or partner agency policies or practices Lack of support for implementation from key leaders at grantee or partner agency Lack of support for implementation from key external stakeholders Other, specify­­­­_______ Other, specify­­­­_______ None
39i. What factors have served as facilitators to implementation of this EBP (i.e. have helped with successful implementation) (check all that apply)	Clear strategic plan for implementing the EBP Adequate financing for the EBP Adequate allocation of staff time/staff resources for EBP implementation Access to on-going training, supervision, and consultation on the EBP Positive practitioner attitudes toward the EBP Prior experience with this EBP Prior experience with other EBPs Supportive state or local policy/regulations Supportive grantee or partner agency policies or practices Support for implementation from key leaders at grantee or partner agency Support for implementation from key external stakeholders Other, specify­­­­_______ Other, specify­­­­_______ None	Clear strategic plan for implementing the EBP Adequate financing for the EBP Adequate allocation of staff time/staff resources for EBP implementation Access to on-going training, supervision, and consultation on the EBP Positive practitioner attitudes toward the EBP Prior experience with this EBP Prior experience with other EBPs Supportive state or local policy/regulations Supportive grantee or partner agency policies or practices Support for implementation from key leaders at grantee or partner agency Support for implementation from key external stakeholders Other, specify­­­­_______ Other, specify­­­­_______ None	Clear strategic plan for implementing the EBP Adequate financing for the EBP Adequate allocation of staff time/staff resources for EBP implementation Access to on-going training, supervision, and consultation on the EBP Positive practitioner attitudes toward the EBP Prior experience with this EBP Prior experience with other EBPs Supportive state or local policy/regulations Supportive grantee or partner agency policies or practices Support for implementation from key leaders at grantee or partner agency Support for implementation from key external stakeholders Other, specify­­­­_______ Other, specify­­­­_______ None

Housing

40. Regarding housing and homelessness, how much is each of the following a focus of your CABHI/GBHI/SSH/PATH project? [PREPOPULATE]
	1 = Not at all (0 or up to 5%)	2 = Somewhat (Less than half)	3 = A lot (The majority- more than half)	4 = Totally (All or almost all are in the category, e.g., at least 90%)
a. Client transition from street to shelter
b. Client transition from street to transitional housing (e.g., time-limited housing such as residential treatment, sober house, etc.)
c. Client transition from street to permanent housing
d. Client transition from shelter to transitional housing
e. Client transition from shelter to permanent housing
f. Client transition from jail or hospital to shelter
g. Client transition from jail or hospital to transitional housing
h. Client transition from jail or hospital to permanent housing
i. Client transition from transitional housing (e.g., time-limited housing such as residential treatment, sober house, etc) to permanent housing (no time-limit)
j. Client housing stability in transitional housing
k. Client housing stability in permanent housing

41. Screening questions for housing types:

	A	B	C
	During the past 6 months [from DATE], approximately how many CABHI/GBHI/ SSH/PATH clients has your CABHI/GBHI/ SSH/PATH project moved into each of the following types of housing? [IF NONE, insert 0]	As of TODAY, how many CABHI/GBHI/SSH/ PATH project clients are currently residing in [name the type of housing]?	Are support services provided to clients? (Only ask for Row e)
a. Emergency housing (short-term, e.g. emergency shelter, crisis housing)				If Column A or B > 0, answer Q42
b. Safe haven2				If Column A or B > 0, answer Q43
c. Housing in Residential Treatment (e.g., therapeutic communities, community residential facilities)				If Column A or B > 0, answer Q44
d. Transitional housing (time-limited (e.g., 2 years or less), e.g., halfway house, three-quarter house, sober homes)				If Column A or B > 0, answer Q45
e. Permanent supportive housing (PSH; housing with no time limit and program participants hold the lease) or Permanent subsidized housing (e.g. affordable housing for seniors, affordable housing for persons with disabilities, public housing)			___Yes ___No	If Column A or B > 0 and Column C = YES, answer Q46 If Column C = NO, no additional questions are asked.
f. Permanent private/unsubsidized housing without support services				No additional questions are asked for this type.
g. Other, specify:				No additional questions are asked for this type.

42 - 46. HOUSING SUBSECTIONS

The following questions apply to grantee agencies that have CABHI/GBHI/SSH/PATH project clients who are currently staying in [HOUSING TYPE].

Please list all the [HOUSING TYPE] programs that serve your project clients and the zip code and county where they are located:

	Zip Code:
	County:
	Zip Code:
	County:
	Zip Code:
	County:
	Zip Code:
	County:
	Zip Code:
	County:

For each of the [HOUSING TYPE] programs listed, complete the following:

1. How is [HOUSING TYPE] provided by the CABHI/GBHI/SSH/PATH project to clients? (Check all that apply)	Yes	No	N/A
Directly provided by the grantee agency
Through internal referral within the grantee agency
Through linkage/referral to a partner agency
Through linkage/referral to an agency other than partner agency
Project clients are on their own, housing is not provided as part of the project (i.e., clients are staying in this emergency housing program but the grantee agency has nothing to do with it.)
Other (specify)
2. Does this [HOUSING TYPE] program receive funding from the following sources? (Check all that apply)	Yes	No	N/A
HUD Tenant-based Emergency Solutions Grant (ESG) funds from a state/local government agency
HUD Project-based ESG funds from a state/local government agency
HUD Community Development Block Grant (CDBG) funds from a state/local government agency
HUD Section 8 Housing Choice Voucher (HCV)
HUD Section 8 Project-based Voucher (PBV)
HUD Tenant-based Shelter Plus Care (S+C) subsidy
HUD Sponsor-based S+C subsidy
HUD Project-based S+C subsidy
HUD Supportive Housing Program funds awarded through the local/state Continuum of Care (program name)
HUD Tenant-based Continuum of Care (CoC) program funds awarded through the local/state CoC
HUD Sponsor-based CoC program funds awarded through the local/state CoC
HUD Project-based CoC program funds awarded through the local/state CoC
HUD-Veterans Affairs Supportive Housing (VASH) vouchers
HUD Housing Opportunities for Persons with AIDS (HOPWA) funds from a state/local government agency
HUD HOME Investment Partnerships Program (HOME) funds from a state/local government agency
State or local government (specify)
Funding from foundations (specify)
Funding from private donations (specify)
Other funding (specify)
3. What types of housing units/apartments are provided by this [HOUSING TYPE] program? (Check all that apply)	Yes	No	N/A
Congregate housing (e.g. all beds or rooms located in the same site with shared common areas)
Single room occupancy (SRO; e.g., single room unit that may have kitchen and/or bathroom facilities in the unit or in a shared space)
Single-site apartments (e.g. 2 or more apartments set aside for the target population in one site)
Scatter-site apartments (e.g. apartments are located in different sites)
Hotels/motels
Other (specify)
4. Does this [HOUSING TYPE] program accommodate client choice with regard to the following? (Check all that apply)	Yes	No	N/A
Choice on housing location (neighborhood where housing is located)
Choice on type of housing unit (bedroom, SRO, apartment)
Choice on receipt of treatment (substance abuse or mental health) or not
Choice on including adult family members in the housing facility
Choice on including children (minors) in the housing facility
Other (specify)
Not able to accommodate client choice
5. Within each of the following categories (e.g., Gender, Age, etc.), please indicate whether or not the [HOUSING TYPE] program: has INCLUSION CRITERIA, that is, clients must meet these criteria/characteristics in order to be admitted into the [HOUSING TYPE] program (may include more than one group per category) will give PRIORITY to one or more of the groups to receive admission into the [HOUSING TYPE] program – that is, the program will prioritize those groups for admission but will also accept others (may include more than one group per category) HOUSES one or more of these groups, but will not house only that group or give them priority for admission (may include more than one group per category)	A	B	C
	Inclusion Criteria: (Yes/No/ Unk) If YES, skip to next row If NO or Unk, answer Column B	Priority: (Yes/No/ Unk/NA) If YES, skip to next row If NO or Unk, answer Column C	Houses: (Yes/No/ Unk/NA)
GENDER	---------	---------	---------
Female clients
Male clients
Transgender clients
AGE	---------	---------	---------
Adult (ages 18 and above) clients (i.e., general adult population, no youth)
Youth (e.g, under 18 years old) clients
BEHAVIORAL HEALTH & TREATMENT STATUS	---------	---------	---------
Clients with mental disorders only
Clients with substance abuse/dependence only
Clients with co-occurring mental and substance use disorders
Clients who are clean and sober
Clients who are actively using alcohol or drugs (e.g., wet or damp)
Clients who demonstrate stability of mental health symptoms
Clients who are compliant with medication
Clients who have reached a certain stage of change/readiness
Clients in a mental health/substance abuse treatment program
Clients who have reached a certain phase of treatment
Clients who have completed treatment
Clients with another behavioral health or treatment status (specify)
HOMELESS POPULATIONS	---------	---------	---------
At risk for becoming homeless (e.g., doubled up, coming out of jail or hospital, couch surfing, temporarily with friends/family) clients
Acutely (first time) homeless clients
Episodically homeless clients
Chronically homeless clients
CLIENTS’ PRIMARY LIVING SITUATION BEFORE ENTRY INTO EMERGENCY HOUSING	---------	---------	---------
Street
Shelter
Housed—transitional housing (e.g., time-limited, residential, sober housing, etc)
Housed—doubled up, couch surfing, living with others (friends and family)
Housed—current institutional to be released from jail/prison
Housed—current institutional to be released from hospital
Housed—in own house, room or apartment (permanent housing, supportive or non-supportive)
Other living situation (specify)
OTHER POPULATIONS	---------	---------	---------
Clients experiencing high levels of housing mobility or instability
Clients who have a criminal justice record
Clients who do not have a criminal justice record
Clients who are reentering from jail or prison
Clients who are currently on probation/parole/court mandate
Clients who are currently not on probation/parole/court mandate
Clients who are chronic public inebriates
Clients who are veterans
Clients who are pregnant
Clients with children/families
Clients without children/families
Clients with a physical or developmental disability
Clients living with HIV/AIDS
Clients who have experienced domestic violence
Clients who are lesbian, gay, bisexual, transgender, or questioning (LGBTQ)
Clients who are undocumented immigrants
Other (specify)
6. Does this [HOUSING TYPE] program require that project clients maintain the following to stay in the housing program? (Check all that apply)	Yes	No	N/A
Compliance with treatment plan and/or participation in formal treatment activities (e.g., attend groups, see a psychiatrist, etc.)
Compliance with medication
Sobriety/Abstinence from drugs and alcohol
Stability of mental health symptoms
Agreement to face-to-face visits with program staff
Agreement to allow program staff to enter clients’ housing unit without prior notification
Other (specify)
7. Does this [HOUSING TYPE] program provide the following types of assistance to project clients to obtain transitional or permanent supportive housing? (Check all that apply)	Yes	No	N/A
Completion of housing application
Preparation for housing interview
Escorting client to housing interview or housing appointments
Contacting or meeting with landlords
Communication with agency that determines housing (e.g., housing authority) to prioritize housing placement with the grantee agency
Provision of assistance accessing move-in resources
Provision of assistance with actual move in
8. Does the staff at this [HOUSING TYPE] program provide the following types of services to project clients… A. …while clients are staying in the [HOUSING TYPE] program? B. …after clients leave the [HOUSING TYPE] program, in order to maintain transitional or permanent supportive housing?	A	B
	While in [HOUSING TYPE]? Yes/No/Unk	After [HOUSING TYPE], to maintain transitional or permanent supportive housing? Yes/No/Unk
Treatment services
Case management services
Supportive services (e.g., furniture, food pantry, managing bill payment, etc.)
9. The following items address the type of agency that provides [HOUSING TYPE] and whether a partner organization provides treatment, case management, and supportive services. (Check “yes” or “no” in reference to this [HOUSING TYPE] program)	Yes	No	N/A
The [HOUSING TYPE] program is operated by a housing agency.
If yes, treatment, case management, and/or supportive services are provided by a social service or treatment agency. [SKIP to Q10]
The [HOUSING TYPE] program is operated by a social service or treatment agency.
If yes, treatment, case management, and/or supportive services are provided by a separate social service or treatment agency. [SKIP to Q10]
The [HOUSING TYPE] program is operated by an agency that is both a housing and social service or treatment agency.
If yes, treatment, case management, and/or supportive services are provided by a separate social service or treatment agency.
10. The following items address the relationship between housing management and treatment, case management, and supportive services. For each item, please check “yes” or “no” in reference to this [HOUSING TYPE] program.	Yes	No	N/A
Management of [HOUSING TYPE] and provision of treatment services are operated by the same organization.
Management of [HOUSING TYPE] and provision of case management services are operated by the same organization.
Management of [HOUSING TYPE] and provision of supportive services are operated by the same organization.
The roles of housing staff (housing management and fee collection) and treatment services staff are distinct from each other (i.e.., housing staff do not provide treatment services and treatment staff do not peform housing management responsibilities).
The roles of housing staff (housing management and fee collection) and case management staff are distinct from each other (i.e., housing staff do not provide case management services and case management staff do not peform housing management responsibilities).
The roles of housing staff (housing management and fee collection) and supportive services staff are distinct from each other (i.e., housing staff do not provide supportive services and supportive services staff do not peform housing management responsibilities).
Treatment service providers are based off-site (i.e., they do not have offices on-site in emergency housing).
Case management providers are based off-site (i.e., they do not have offices on-site in emergency housing).
Supportive services providers are based off-site (i.e., they do not have offices on-site in emergency housing).
11. Which of the following best describes the housing philosophy of this [HOUSING TYPE] program? (Select only one)
Housing first (i.e., rapid placement in permanent housing with limited or no transitional placements)
Housing ready (i.e., people need to address issues that may have led to their own homelessness before they enter permanent housing)
A mixture of housing first and housing ready
Other (specify)
Unknown
12. Please indicate the average percentage of income paid by project clients in order to stay in this [HOUSING TYPE] program. (Select only one)
Client does not pay
Pay 30% or less of their income for housing costs
Pay 31-40% of their income for housing costs
Pay 41-50% of their income for housing costs
Pay more than 50% of their income for housing costs
13. The following is a list of items concerning the way services (including treatment, case management and supportive services) are delivered to your project clients in this [HOUSING TYPE] program. (Check all that apply)	Yes	No	N/A
Project clients are the primary authors of their service plans at program entry.
Project clients are offered the opportunity to modify their service plans (.e.g., modify their selection of services) on an ongoing basis.
Project clients must participate in services that staff identify.
Project clients have input into design and provision of services (e.g., consumer advisory board).
Caseload is no more than 15 project clients to each FTE treatment service staff member.
Caseload is no more than 15 project clients to each FTE case management service staff member.
Caseload is no more than 15 project clients to each FTE supportive service staff member.
14. Please indicate which one of the following best describes this [HOUSING TYPE] program’s policy regarding client’s maximum length of stay. (Select only one)
Less than 6 months
6 months – less than 12 months
12 months – 24 months
No specified length of stay
Other (specify)
15. The following is a list of items concerning the tenancy status of project clients in this [HOUSING TYPE] program. (Check all that apply)	Yes	No	N/A
Clients stay in the [HOUSING TYPE] program without a rental lease
The CABHI/GBHI/SSH/PATH project holds a rental lease and master-leases it to clients
The housing agency holds a rental lease and master-leases it to clients
Clients holds a rental lease under his/her name. There is no master-leasing.

CABHI/GBHI/SSH/PATH Project Organization and Implementation

47. The following statements refer to your agency or organization’s CABHI/GBHI/SSH/PATH project staff experience with cultural competence, gender services and trauma and consumer involvement. The statements are worded for grantees that are currently operating. If your local CABHI/GBHI/SSH/PATH grant has ended, please think about the situation just prior to the grant ending. Please indicate the extent to which you agree or disagree.

Please indicate the extent to which you agree or disagree with the following statements about the services provided by your agency or organization:	Strongly agree (SA), agree (A), neither agree nor disagree (N), disagree (D), or strongly disagree (SD)
	SA	A	N	D	SD
a. Our staff has experience serving the target population (e.g., homeless youth, adults or families with substance use and/or co-occurring mental disorders)
b. Our staffing has diversity reflecting the target population
c. We have specific plans to overcome language barriers (bilingual staff, instruments in various languages)
d. Treatment and/or support services were selected based on specific effectiveness/appropriateness to the target population’s age, gender, race or ethnicity.
e. We have had training(s) on cultural sensitivity
f. We have planned future training(s) to increase cultural sensitivity
g. We assess the client’s trauma history
h. We offer trauma-specific treatment or other services
i. We have had training(s) on trauma-informed treatment or services
j. We have planned future training(s) on trauma-informed treatment or services
k. Our agency (not just the CABHI/GBHI/SSH/PATH project) generally offers gender-specific services
l. The CABHI/GBHI/SSH/PATH project offers gender-specific treatment or services options
m. We have had training(s) on gender-specific treatment or other services
n. We have planned future training(s) on gender-specific treatment or other services
o. Our clients have choice in selecting treatment or other services in which to participate
p. Our clients have choice in selecting type of housing/locations/configurations
q. Clients/consumers serve as paid staff members
r. Other, specify:________________________________

48. The following statements refer to the implementation and operation of your local CABHI/GBHI/SSH/PATH project. The statements are worded for grantees that are currently operating. If your local CABHIGBHI/SSH/PATH grant has ended, please think about the situation just prior to the grant ending. Please indicate the extent to which you agree or disagree.

Please indicate the extent to which you agree or disagree with the following statements about the implementation and operation of your CABHI/GBHI/SSH/PATH project:	strongly agree (SA), agree (A), neither agree nor disagree (N), disagree (D), or strongly disagree (SD)
	SA	A	N	D	SD
a. Information sharing about specific clients among partners has improved as a result of CABHI/GBHI/SSH/PATH
b. Communication among partnering organizations has improved as a result of CABHI/GBHI/SSH/PATH
c. CABHI/GBHI/SSH/PATH partners have created common goals as a result of the CABHI/GBHI/SSH/PATH project
d. Support for the CABHI/GBHI/SSH/PATH project from grantee agency line staff has been strong
e. Support for the CABHI/GBHI/SSH/PATH project from housing partner(s) line staff has been strong
f. Support for the CABHI/GBHI/SSH/PATH project from substance abuse treatment partner(s) line staff has been strong
g. Support for the CABHI/GBHI/SSH/PATH project from mental health treatment partner(s) line staff has been strong
h. Support for the CABHI/GBHI/SSH/PATH project from housing partner(s) administration has been strong
i. Support for the CABHI/GBHI/SSH/PATH project from substance abuse treatment partner(s) administration has been strong
j. Support for the CABHI/GBHI/SSH/PATH project from mental health treatment partner(s) administration has been strong
k. CABHI/GBHI/SSH/PATH has increased clients’ willingness to access available services
l. CABHI/GBHI/SSH/PATH has increased my agency or organization’s capabilities to provide clients effective and appropriate services
m. The CABHI/GBHI/SSH/PATH project has tapped into other federal, state or local government funding to enhance its activities during CABHI/GBHI/SSH/PATH funding
n. The CABHI/GBHI/SSH/PATH project has tapped into federal, state or local government funding to sustain its activities after CABHI/GBHI/SSH/PATH funding ends
o. My agency has been involved in sustainability planning to help the CABHI/GBHI/SSH/PATH project continue after CABHI/GBHI/SSH/PATH funding ends
p. The CABHI/GBHI/SSH/PATH project has implemented targeted approaches and strategies as planned
q. The CABHI/GBHI/SSH/PATH project has effectively overcome obstacles or setbacks
r. CABHI/GBHI/SSH/PATH has improved integration of services for target clients in our community
s. CABHI/GBHI/SSH/PATH has fostered coordination between different types of service providers
t. The CABHI/GBHI/SSH/PATH project includes members from all relevant agencies or organizations that are necessary to successfully implement the project
u. Our CABHI/GBHI/SSH/PATH project has clear criteria on how resources are allocated
v. CABHI/GBHI/SSH/PATH goals and strategies are well-focused
w. CABHI/GBHI/SSH/PATH has effectively utilized pre-existing community capabilities and assets
x. CABHI/GBHI/SSH/PATH efforts have been undercut by turf battles or in-fighting
y. CABHI/GBHI/SSH/PATH has had insufficient involvement from agency leaders
z. CABHI/GBHI/SSH/PATH has used too much of a “top down” approach
aa. CABHI/GBHI/SSH/PATH has used too much of a “bottom up” approach
bb. Staff turnover has limited effectiveness of CABHI/GBHI/SSH/PATH activities
cc. CABHI/GBHI/SSH/PATH has placed too much emphasis on substance abuse treatment and/or mental health treatment, at the expense of housing
dd. CABHI/GBHI/SSH/PATH has placed too much emphasis on housing, at the expense of substance abuse treatment and/or mental health treatment
ee. CABHI/GBHI/SSH/PATH has had little effect on moving clients into permanent housing
ff. CABHI/GBHI/SSH/PATH has had little effect on integrating housing and support and treatment services
gg. Formal interagency agreements (e.g., MOUs) have facilitated CABHI/GBHI/SSH/PATH efforts
hh. CABHI/GBHI/SSH/PATH has fostered development of uniform application, eligibility criteria, or intake assessments
ii. CABHI/GBHI/SSH/PATH efforts have been supported by co-location of services
jj. CABHI/GBHI/SSH/PATH has increased use of interagency MIS or client tracking systems
kk. The CABHI/GBHI/SSH/PATH project has focused on the wrong clients
ll. CABHI/GBHI/SSH/PATH has had little effect on how my agency or organization serves clients
mm. CABHI/GBHI/SSH/PATH will have little lasting impact on the treatment system in our community
nn. TA provided under CABHI/GBHI/SSH/PATH has helped my agency or organization contribute to CABHI/GBHI/SSH/PATH objectives
oo. Evaluation findings are used early in the CABHI/GBHI/SSH/PATH project to help inform project implementation
pp. Interim evaluation findings are used in the CABHI/GBHI/SSH/PATH project to help with sustainability efforts

49. The following questions address barriers that may have impacted project implementation and service delivery.

Please indicate the extent to which you agree or disagree that the following barriers impacted implementation and/or service delivery for the CABHI/GBHI/SSH/PATH project:	strongly agree (SA), agree (A), neither agree nor disagree (N), disagree (D), or strongly disagree (SD)
	SA	A	N	D	SD
a. Difficulties hiring qualified staff
b. Difficulties retaining qualified staff
c. Shortfalls in recruiting or enrolling target clients
d. Client reluctance to access CABHI/GBHI/SSH/PATH services
e. Difficulties retaining target clients in CABHI/GBHI/SSH/PATH project
f. Difficulties following up with clients in CABHI/GBHI/SSH/PATH project for GPRA/NOMs reassessments
g. Difficulties providing services as planned
h. Existing agency rules or regulations
i. Other, specify: ____________________________

Sustainability [skip out for all PATH grantees]

The following questions address issues associated with your CABHI/GBHI/SSH project’s efforts toward sustaining the project.

50. Has your CABHI/GBHI/SSH project begun sustainability planning (for completed projects—did the project engage in sustainability planning)? [PREPOPULATE]	Yes No [If no, SKIP to Q54]
50a. When did sustainability planning begin?	___Grant Year 1 ___Grant Year 2 ___Grant Year 3 ___Grant Year 4 ___Grant Year 5
51. Which type of stakeholders are directly involved in your sustainability planning and/or efforts for the CABHI/GBHI/SSH project?	___Social services ___Substance abuse treatment provider ___Mental health treatment provider ___Housing provider ___Shelter ___Medical treatment provider ___Education ___Employment/job training ___Veterans agency ___Criminal justice agency ___Consumer/family ___Policy/Legislator ___Evaluation/Research ___Case management ___Funder (e.g., city/state/federal/foundation) ___Advocacy ___Advisory ___TA/Training ___Other, specify:
52. Does your CABHI/GBHI/SSH project have a written sustainability plan? [IF YES answer Q52a-Q52c]:	Yes No [If no, SKIP to Q53]
52a. When was the written sustainability plan developed?	___Grant Year 1 ___Grant Year 2 ___Grant Year 3 ___Grant Year 4 ___Grant Year 5
52b. Does the sustainability plan identify potential funding sources to replace CABHI/GBHI/SSH grant funds?	Yes No
52c. Does the plan identify strategies for promoting the project?	Yes No
53. Does sustainability planning incorporate local evaluation data and findings to promote sustainability activities?	Yes No [If no, SKIP to Q54]
53a. When is evaluation data used to promote sustainability and funding efforts?	___Grant Year 1 ___Grant Year 2 ___Grant Year 3 ___Grant Year 4 ___Grant Year 5
54. Since you received the original CABHI/GBHI/SSH grant, were any of the following types of funding received for the operation of the CABHI/GBHI/SSH project? (check all that apply)	___ No additional funds received ___ Supplemental CABHI/GBHI/SSH funds $_____ ___ Other SAMHSA funding $ _____ ___Conversion to Medicaid reimbursed services ___ Other non-Medicaid Federal government funding $ _____ ___ State government funding $_____ ___ Local government funding $ _____ ___ Private funding $ ______ ___ In-kind services (type of services: __________________)
55. Are there other homeless initiatives (e.g., 10-year plan to end homelessness) under way in the community?	Yes No
56. What are the plans for continuing the CABHI/GBHI/SSH project once CABHI/GBHI/SSH funds are no longer available?	___Expand the project (e.g., serve a larger number of clients and/or offer more services than the original project) ___Continue the project at the current level ___Retain only some elements/activities of the original project ___End the project [if selected, SKIP to 56b] ___Other, specify:________________________
56a. Do you have sufficient resources to continue the project at the current level following cessation of CABHI/GBHI/SSH funding?	Yes No Too soon to tell [All answers, SKIP to 57]
56b. [Answer only if “End the project” is selected in 56] Indicate the main reasons that the grantee is NOT planning to continue the CABHI/GBHI/SSH project once CABHI/GBHI/SSH funds are no longer available? (check all that apply)	___ Insufficient funding ___ Lack of support from partnering agencies ___ Too many barriers to program implementation and operation ___ Insufficient numbers of eligible participants ___ Program model was not viewed as successful ___ Other, specify:
57. Please indicate which sustainability efforts your CABHI/GBHI/SSH project has engaged in during the course of CABHI/GBHI/SSH funding: (check all that apply) [PREPOPULATE]	Held sustainability planning meetings Assessed the stakeholder/partners’ satisfaction/feedback about project implementation Assessed progress achieved compared with original goals and objectives Assessed resource needs Developed a written sustainability plan Developed MOAs/MOUs with partnering agencies Sought out other partnering agencies Pursued additional federal funding Pursued additional state funding Pursued additional funding from local sources Pursued additional funding from private funding sources Reallocated resources within the grantee agency in order to continue CABHI/GBHI/SSH Reallocated resources across the partnering agencies in order to continue CABHI/GBHI/SSH Obtained reimbursement for CABHI/GBHI/SSH services (Medicaid) Cross-training of staff in mental health and substance abuse treatment Staff was provided training in effective implementation of EBP’s chosen Sustainability planning will incorporate and make use of local evaluation data and findings Made plans to continue EBP implementation/services after funding ends Publicized project acomplishments Other, specify:_____________________ Other, specify:_____________________ Other, specify:_____________________

Technical Assistance

The following questions refer to the grantee’s requests for and receipt of technical assistance (TA).

58. Has your CABHI/GBHI project used the SAIS GPRA helpdesk?

Yes

No

58a. If yes, what type of technical assistance did you receive? _____________________________

59. Has your SSH project used the TRAC NOMs helpdesk?

Yes

No

59a. If yes, what type of technical assistance did you receive? _____________________________

60. Has your CABHI/GBHI/SSH/PATH project requested Technical Assistance from CSAT/CMHS or the Homeless and Housing Resource Network (HHRN)?

Yes [If YES, answer Q61 & 62]

No [If NO, SKIP to Q63]

61. [If yes to Q60] The following questions refer to your project’s requests for and receipt of technical assistance (TA). Please indicate if your project requested the listed type of TA. If yes, indicate if the TA was received and, if it was received, if the TA was helpful.

	Type of TA	Requested?	If requested: Received?	If received: Was it helpful?
a.	Program implementation	Y N DK	Y N DK	Y N DK
b.	Staff training on housing Evidence-Based Practices (EBPs; e.g., Permanent Supportive Housing (PSH), Housing First)	Y N DK	Y N DK	Y N DK
c.	Staff training on other EBPs	Y N DK	Y N DK	Y N DK
d.	Staff development (non-EBP)	Y N DK	Y N DK	Y N DK
e.	Consumer involvement (in program, evaluation, board, etc.)	Y N DK	Y N DK	Y N DK
f.	Quality Assurance (QA)/Continuous Quality Improvement (CQI)	Y N DK	Y N DK	Y N DK
g.	Increasing enrollment/retention (e.g., GPRA/NOMS processes)	Y N DK	Y N DK	Y N DK
h.	GPRA/NOMS performance outcomes (e.g., abstinence, housing stability, etc)	Y N DK	Y N DK	Y N DK
i.	Workforce stability	Y N DK	Y N DK	Y N DK
j.	Financing/financial management	Y N DK	Y N DK	Y N DK
k.	Management Information System (MIS)/electronic records	Y N DK	Y N DK	Y N DK
l.	Linkages/partnerships/referrals	Y N DK	Y N DK	Y N DK
m.	Sustainability	Y N DK	Y N DK	Y N DK
n.	Housing skills training	Y N DK	Y N DK	Y N DK
o.	Housing resources	Y N DK	Y N DK	Y N DK
p.	Fidelity evaluation	Y N DK	Y N DK	Y N DK
q.	Data management	Y N DK	Y N DK	Y N DK
r.	Data analysis/analytic skills	Y N DK	Y N DK	Y N DK
s.	Cost effectiveness evaluation	Y N DK	Y N DK	Y N DK
t.	Other evaluation Technical Assistance, Specify:	Y N DK	Y N DK	Y N DK
u.	Cultural competence	Y N DK	Y N DK	Y N DK
v.	Dissemination	Y N DK	Y N DK	Y N DK
w.	Other, specify:	Y N DK	Y N DK	Y N DK

62. If your CABHI/GBHI/SSH/PATH project received any TA, did the TA affect any of the following aspects of the implementation of your project? (check all that apply)

___Number of project staff

___Type and/or level of project staff

___Type of partnerships

___Target enrollment

___Change in recruitment site or geographic area

___Location of services

___Number of EBPs offered to clients

___Type of EBPs offered to clients, specify: __________________________________________________

___Conversion to Medicaid

___Evaluation design

___Other, specify:_______________________________________________________________________

Local Evaluation [skip out for all PATH grantees]

63. Please describe the Evaluator: (check all that apply)

[PREPOPULATE]

___Independent Evaluator (from a private/not-for-profit organization)

___Independent University-Based Evaluator

___Agency Internal Evaluation/Quality Assurance Unit

___Program Director or Other Grantee Staff

___No evaluator

64. Data Management Information Systems: [PREPOPULATE] (Check all that apply)

This applies to the data sources and MIS your project is using.

___SAIS-GPRA or TRAC/NOMs only

___HMIS

___Electronic Medical records

___Service Utilization data base (services received and collected)

___Medicaid/Medicare

___SOAR Online Application Tracking (OAT)

___State/local Criminal Justice database ( ___arrest; ___court; ___probation/parole; ___unknown)

___Local Shelter database, specify___________

___VA database

___Other _____________

65. Are you conducting a process study? [PREPOPULATE]

___Yes

___No [SKIP to Q66]

65a. [If Yes to Q65] Which process evaluation methods are being used (Check all that apply):

[PREPOPULATE]

___Focus groups

Specify: ____client, ____staff, ____partners, ____others, specify:____________________

___Key informant interviews

Specify: ____client, ____staff, ____partners, ____others, specify:____________________

___Document review

Describe:________________________________________________________________

___Observation

___Other, specify:_____________________________________________________________

65b. [If Yes to Q65] What is being addressed by the process study? (Check all that apply)

[PREPOPULATE]

___Services access (e.g., referral) and services received (including length of service receipt)

Describe: ________________________________________________________ _________________

___Housing placement and housing retention (including length of stay)

Describe:________________________________________________________ _________________

___Comparison of grant proposed versus implemented services (including barriers and facilitators)

Describe: ________________________________________________________ _________________

___Workforce Training

Describe: ________________________________________________________ _________________

___Infrastructure development

Describe: ________________________________________________________ _________________

___Partnerships and collaboration

Describe: ________________________________________________________ _________________

___Program improvement (QI/QA/CQI)

Describe: ________________________________________________________ _________________

___Effect of program on community, services, and systems

Describe: ________________________________________________________ _________________

___ Other, specify:_____________________________________________________

Describe: ________________________________________________________ _________________

66. Are consumers/peers part of evaluation staff? [PREPOPULATE]

Yes No

67. Please describe the involvement of the Evaluator in the activities of the CABHI/GBHI/SSH project: (Check all that apply)

[PREPOPULATE]

Writes evaluation portion of progress report (quarterly, biannual)

Writes program portion of progress report (quarterly, biannual)

Writes annual evaluation report

Attends program/agency Quality Assurance meetings

Attends stakeholder meetings

Participates in sustainability planning

Prepares presentations

Prepares journal articles

Prepares client-level outcomes data reports; for:

____ QA meeting;

____ program team meetings;

____ partner/stakeholder meetings;

____ for sustainability/funding planning;

____ agency board;

____ other (specify ____________________)

Prepares process data reports (e.g. on partnerships, progress toward program implementation goals and objectives); for:

____ QA meeting;

____ program team meetings;

____ partner/stakeholder meetings;

____ for sustainability/funding planning;

____ agency board;

____ other (specify ____________________)

Helps program select and/or implement EBP

Attends clinical staff meetings

Collects data

Provides training/TA to program staff or others on data collection

Enters GPRA/NOMs data on SAIS/TRAC system

Enters data into another system (specify types of data and types of systems: ____________)

Other, specify ________

68. Does the evaluation or project administer additional measures other than the GPRA/NOMS for process and or outcome evaluation? [PREPOPULATE]

Yes No [If No, Skip to Q70]

69. If YES to Q68, please complete the table:

Name of Measure (e.g., Brief Symptom Inventory, Addiction Severity Index, etc)—cite source if it is a standardized measure [PREPOPULATE]	Implemented (is the instrument being used by the local evaluation) YES/NO [If NO, SKIP to next Measure row]	Type of Measure 1. Client assessment 2. Client self-report symptom measure 3. Satisfaction assessment 4. Services Referred, Received, Dosage 5. Partnerships/Collaboration 6. Cultural Competence Assessment 7. Sustainability 8. Other, specify:___ [PREPOPULATE]	From whom is the data collected: (select all that apply) 1. Client 2. Client’s family 3. Staff 4. Partner/Stakeholder 5. Other, specify:___ [PREPOPULATE]	When will it be administered? (select all that apply) 1. Baseline 2. 6-months post baseline 3. Every 6 months 4. 12-months post baseline 5. Discharge 6. Annual 7. Quarterly 8. Other, specify [PREPOPULATE]

70. Please list three main obstacles to evaluation/data collection and three main successes in implementing your local evaluation:

A. Obstacles	B. Successes
1.	1.
2.	2.
3.	3.

Lessons Learned

71. For the grantee: Please describe the one most important lesson learned during the implementation of your CABHI/GBHI/SSH/PATH project for each of the areas below. In other words, what do you know now that you wish you had known when you started your project?

1. Lesson learned about serving target population

2. Lesson learned about implementing the project

3. Lesson learned about implementing an evidence-based practice (EBP)

4. Lesson learned about partner collaboration

5. Lesson learned about sustainability

1 Rehabilitation approach: focuses on problems that disturb the client’s ability to function in everyday life and sets concrete goals in treatment planning where services received and goals set are based on client choice. All treatment and services received are integrated and there are no time limits set on access to treatment or services. Client’s strengths and deficiencies are assessed and built upon or strengthened through skills training, respectively. The client works toward building social networks and becoming a part of his or her community thus decreasing reliance on treatment providers. When needed, the client’s environment is modified to maximize success (e.g., moving out of a negative environment).

Strengths-based approach: includes four strengths-based practice approaches: strengths case management, solution-focused therapy, individual placement and support model of supported employment, and the asset building model of community development. These practice approaches all have the following characteristics: goal-oriented, systematic assessment of strengths, client’s environment is seen as rich in resources, use of explicit methods for using client and environmental strengths for goal attainment, provider-client relationship is hope-inducing, and clients have the authority to choose and are provided with meaningful choices.

Prescriptive approach: based on the idea that there is not a ‘one size fits all’ treatment model. Clients bring with them different personal characteristics and varying degrees of severity in regard to addiction or mental illness. This needs to be taken into account during treatment planning and used to find the best practices for that particular client. Clients are assessed on certain domains (e.g., functional impairment, coping style, resistance traits, etc) and these measurements are matched to the appropriate treatment methods needed. Once treatment needs are assessed, the most suitable treatment methods are chosen, tailoring the treatment planning to each client.

Confrontation approach: confrontation techniques that focus on behaviors relevant to recovery only, not behavior in general, and how continuation of addictive behaviors can have negative consequences for the client. Confrontation can come from many different sources, not just treatment staff, including family/friends, the workplace, peers in treatment, criminal justice professionals, etc. The following elements have been identified for use in effective confrontation therapy: a focus on behaviors or thinking clearly related to substance misuse, implementation of confrontation within the context of a trusting relationship, consideration of the nature of the treatment setting and characteristics of the client, and avoidance of extreme expression of emotion that can detract from the content of the confrontation.

Continuum of Care (CoC): a community level service delivery model that incorporates a wide range of services for individuals who are homeless or at risk for homelessness. It is based on the idea that providing temporary shelter is not enough to eliminate homelessness; it is necessary to also focus on prevention, outreach, assessment, and assisting people every step of the way from immediate emergency shelter to permanent affordable housing. Another important tenet of CoC is that the homeless also require assistance in receiving supportive services in other areas like substance abuse, mental health, and employment. This is often a multi-agency system within the community that coordinates to provide all of these services to the homeless. Clients receive housing services in a step-wise fashion, beginning with emergency shelter to transitional housing to permanent supportive housing to permanent affordable housing having to complete each step successfully before moving on to the next. As defined by the U.S. Department of Housing and Urban Development, CoC’s contain the following seven components: prevention, outreach and assessment, emergency shelter, transitional housing, permanent supportive housing, permanent affordable housing, and supportive services.

2 A safe haven is a form of supportive housing that serves hard-to-reach homeless persons with severe mental illness who are on the street and have been unable or unwilling to participate in supportive services. Characteristics of safe havens include: 1) 24-hour residence for eligible persons who may reside for an unspecified duration; 2) private or semiprivate accommodations; 3) overnight occupancy limited to 25 persons; 4) low-demand services and referrals; and 5) supportive services to eligible persons who are not residents on a drop-in basis (Title IV, Subtitle D of the McKinney Act, 1992 from Safe Havens Toolkit, undated, retrieve from http://www.hudhre.info/documents/SafeHavens.pdf, p.3).