Form 10-10161 Veteran Assessment

CHALENG (Community Homelessness Assessment, Local Education and
Networking Groups), Veteran Needs Assessment
OMB No. 2900-xxxx
Estimated Burden: 5 minutes per respondent
Expiration Date: xx/xx/xxxx

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of
the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required
to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who complete this survey will average 585 hours, or 5 minutes per respondent.
This includes the time it will take to follow instructions, gather the necessary facts and respond to questions
asked. The results of this needs assessment will lead to improvements in the quality of service delivery by
helping to identify gaps in Homeless Program services, and designing new services to fill those gaps.
Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you
may be entitled.
VA Form 10APR 2014

1

2015 CHALENG
Survey
Identification

OMB Number: 2900-XXXX
Estimated Burden: 5 mins
Expiration Date: XX/XX/XXXX

Please only answer this question if you answered question #2 with
“unsubsidized housing.”

1. In which branch of the armed services did you
serve?
Army

All other Veterans should skip question 2(c).

Navy
Marine Corps

(2c) Do you own or rent?

Air Force

Own

Coast Guard
National Guard/Reserve

3. What is your gender?

2. Where are you living now?

Male

Literally Homeless (on streets, in shelter, car, etc.)
Transitional housing (Grant and per Diem housing, VA Domiciliary,
or community contract housing)
Permanent subsidized housing (including VASH and Section 8)
Unsubsidized housing (private apartment/house/condominium)
Please only answer these questions if you answered question #2
with “literally homeless.”
All other Veterans should skip questions 2(a) and 2(b).

7-12 months

13-24 months

More than 24 months
(2b) Have you had four or more episodes of homelessness in the past
three years?
Yes

No

Less than 25

45-60

25-34

61+

35-44
5a. What race do you most strongly identify with?
American Indian or Alaskan
Don't Know
Asian
Black or African American
Native Hawaiian or Other Pacific Islander

(2a) Which of the following options best describes how long you have
been homeless?
4-6 months

Female

4. What is your age?

Emergency Housing

0-3 months

Rent

White
5b. What ethnicity do you most strongly identify with?
Non-Hispanic/Non-Latino

Don't Know

Hispanic/Latino
6. How many dependents under the age of 18 are residing with you?
0

1

2

3

4 or more

7. Are you currently enrolled in the VA?
Yes

No

8. Is your housing in any way at risk (do you have trouble making mortgage payments,
or are your housing plans uncertain?)
Yes

No

9. Do you live in a rural or frontier community?
Yes

No

9. Goods (Furniture and Housewares) for New
Apartment

Treatment Services
Never
Met

Always
Met N/A

1. Medical Services

Income/Benefits Services:
Never
Met

Always
Met N/A

1. VA Disability/Pension
2. Welfare Payments

2. Services for Emotional or Psychiatric
Problems
3. TB Testing and Treatment

3. Supplemental Security Income (SSI) and Social Security
Disability (SSD)
4. Money Managing

4. Dental Care

5. Food

5. Detoxification from Substance

6. Clothing

6. Substance Abuse Treatment

7. Credit Counseling

7. HIV/AIDS Testing and Treatment

8. Family Reconciliation Assistance

8. Hepatitis C Testing and Treatment

9. Social Networking

9. Eye Care and Glasses

10. Move- In Assistance

10. Personal Hygiene (shower, haircut, etc.)

11. Utility Assistance

11. Medication Management

12. Discharge Upgrade

12. Elder Healthcare and Resources

13. Family and Marital Counseling

13. Health and Wellness**

14. Transportation***

14. Treatment for Dual Diagnosis

15. Child Care

15. Case Management

16. Basic Services (phone, voicemail, address)

16. Parent Education

17. Financial Assistance to Prevent Eviction or Foreclosure

17. Military Sexual Trauma
*N/A: non-applicable
**Health and Wellness: an overall approach to health and well being that emphasizes
preventing illness and prolonging life through diet, exercise, exercise, and self care

***Transportation: includes transportation for disabled Veterans and Veterans with dependent children

Legal Assistance:

1. Education
2. Job Training
3. Finding a Job or Getting Employment
4. Life Skills Training*

*Life skills training: learning to cope with stresses and challenges of daily life, particularly skills in communication,
literacy, decision-making, occupational requirements, problem-solving, time management, and planning
**Vocational Rehabilitation:a process that enables people with functional,psychological, developmental, cognitive,
or emotional impairments or health conditions to overcome barriers to accessing, maintaining, or returning
to
employment

5. Vocational Rehabilitation**

Community Partnerships:
Always
Met N/A

1. Drop-in Center and Day Program
2. Spiritual
3. Prevention***
Not
Accessible

Very N/A
Accessible

Not
Able

Mostly
Able N/A

Not
Aware

Mostlly N/A
Aware

***Prevention: services to stop Veterans and their families from becoming homeless, including ways to avert
housing
loss for households facing eviction and housing resources when discharged from hospital, jails, and
prisons

4. In general how accessible do you feel VA services are to homeless Veterans in your community?
5. How able is the VA to coordinate services for homeless Veterans?
6. How aware of Veterans’ needs and resources are Community Homeless Agencies?

Thank you for your participation in the CHALENG survey! If you would like more information or if you have any concerns,
please contact the Call Center for Homeless Veterans:
http://www.va.gov/homeless/nationalcallcenter.asp | 1-877-4AID VET (1-877-424-3838)