Form 10-10162 Provider Assessment

CHALENG (Community Homelessness Assessment, Local Education and
Networking Groups), Provider Needs Assessment
OMB No. 2900-xxxx
Estimated Burden: 8 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 1,067 hours, or 8 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
Respondent
1. Which of the following best describes your reasons for taking the
CHALENG survey?
I work for the VA
I work for another Federal Agency
I work for a state or local government agency or a community-based
homeless provider
I am an interested member of the community
2. Did you complete a CHALENG survey last year?
Yes

No

3. In your opinion, is the agency you represent faith-based?
Yes

No

OMB Number: 2900XXXXĀ
Estimated Burden: 8
minsĀ
Expiration Date: XX/XX/XXXX

Please only answer if you indicated that you work for a Federal agency other
than the VA.
1b. Which of the following best describes your organizational
affiliation?
Department of Housing and Urban Development
Department of Labor
United States Interagency Council for Homelessness
Department of Health and Human Services
Department of Education
Department of Defense
Social Security Administration
Department of Agriculture
Department of Justice
Department of Transportation

Provider’s Identification

Department of the Interior
Other
Please only answer if you DO NOT work for the federal government.

Please only answer if you indicated that you work for the VA.
1a. Which of the following best describes your organization and
affiliation?
VA Central Office
Veterans Benefit Administration
VA National Cemetery Administration
VISN
VA Medical Center
VA Regional Office
VA Outpatient Clinic
Vet Center

1c. Which of the following best describes your organizational affiliation?
State Department of Veterans Affairs
State or Local Health and Human Services Agency
State or Local Mental Health Department
State or Local Correctional Agency or Law Enforcement Organization
Other State or Local Government Agency
Veterans Services Organization
Private Non-profit Community-based Organization
Private For-profit Community-based Organization
Other

Based on your experience serving homeless Veterans, please help us understand how well the needs of male and female Veterans are being
met in the following areas:

Housing

(Treatment Services continued)
Never
Met

Always
Met N/A*

Never
Met

Always
Met N/A*

Never

1. Emergency/Immediate Shelter

Male

Female

4. Dental Care

Male

2. Transitional Living Facility
andHalfway
House

Male

Female

5. Detoxification from Substance

Male

3. Long-Term Permanent Housing

Male

Female

6. Substance Abuse Treatment

Male

4. Registered Sex Offender Housing

Male

Female

7. HIV/AIDS Testing and Treatment

Male

5. Affordable Housing

Male

Female

8. Hepatitis C Testing and Treatment

Male

6. Emergency Housing for Families

Male

Female

9. Eye Care and Glasses

Male

7. Landlord Relations and Tenancy

Male

Female

10. Personal Hygiene (Shower,
Haircut, etc.)

Male

8. Assisted Living for the Elderly

Male

Female

11. Medication Management

Male

9. Goods (Furniture and
Housewares)
for New
Apartment

Male

Female

12. Elder Healthcare and Resources

Male

13. Health and Wellness*

Male

14. Treatment for Dual Diagnosis

Male

Treatment Services
1. Medical Services

Male

Female

15. Case Management

Male

2. Services for Emotional
or Psychiatric
Problems

Male

Female

16. Parent Education

Male

17. Military Sexual Trauma

Male

3. TB Testing and Treatment

Male

*N/A: non-applicable

Always

N/A

Never

Always

N/A

Female

Female
*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

Income/Benefits Services:
Never
Met

Legal Assistance:

Always
Met N/A

Never
Met

Always
Met N/A

1. VA Disability/Pension

Male

Female

2. Welfare Payments

Male

Female

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

Male

Female

4. Money Managing

Male

Female

5. Food

Male

Female

6. Clothing

Male

Female

7. Credit Counseling

Male

Female

8. Family Reconciliation Assistance

Male

Female

9. Social Networking

Male

Female

10. Move- In Assistance

Male

Female

Education/Job Services:

11. Utility Assistance

Male

Female

1. Education

Male

12. Discharge Upgrade

Male

Female

2. Job Training

Male

13. Family and Marital Counseling

Male

Female

3. Finding a Job or Getting
Employment

Male

14. Transportation*

Male

Female

4. Life Skills Training*

Male

15. Child Care

Male

Female

5. Vocational Rehabilitation**

Male

16. Basic Services (Phone,
Voicemail, Address)

Male

Female

17. Financial Assistance to Prevent
Eviction or Foreclosure

Male

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

and Foreclosure

*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

Community Partnerships:

Women’s Issues:

2. Spiritual

Male

Female

3. Prevention*

Male

Female

*Prevention: services to stop Veterans and their families from becoming homeless, including
wayshousing
to
avert
loss for households facing eviction and housing resources when discharged from
hospital,
jails, and
prison
Not
Accessible

4. In general how accessible do you
feel VA services are to homeless
Veterans in your community?

Male

Mostly
Able N/A

Male

Male

Very
N/A
Accessible

Not
Able

Mostly
Able N/A

Not
Aware

Mostlly
N/A
Aware

Female

Not
Aware

6. How aware of Veterans’ needs and
resources are community homeless
agencies?

Not
Accessible

Female

Not
Able

5. How able is the VA to coordinate
services for homeless Veterans?

Very
N/A
Accessible

Mostlly
N/A
Aware

Female

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)