VDHS Attachments

OMB Generic Clearance to conduct the Victims with Disabilities in Homeless Shelters Pilot Survey (under
OMB Number 1121-0325)
LIST OF ATTACHMENTS
1.
2.
3.
4.
5.
6.

BJS Statute: 34 USC 10132
Pilot Study Instrument
Version 1 of the Pilot Study Instrument Pre-Cognitive Testing
Recruitment Letter
Frequently Asked Questions
Informed Consent

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Attachment 1
34 USC 10132: Bureau of Justice Statistics
Text contains those laws in effect on January 15, 2018
From Title 34-CRIME CONTROL AND LAW ENFORCEMENT
Subtitle I-Comprehensive Acts
CHAPTER 101-JUSTICE SYSTEM IMPROVEMENT
SUBCHAPTER III-BUREAU OF JUSTICE STATISTICS
Jump To:
Source Credit
References In Text
Codification
Prior Provisions
Amendments
Effective Date
Miscellaneous

§10132. Bureau of Justice Statistics
(a) Establishment
There is established within the Department of Justice, under the general authority of the Attorney General, a Bureau
of Justice Statistics (hereinafter referred to in this subchapter as "Bureau").
(b) Appointment of Director; experience; authority; restrictions
The Bureau shall be headed by a Director appointed by the President. The Director shall have had experience in
statistical programs. The Director shall have final authority for all grants, cooperative agreements, and contracts
awarded by the Bureau. The Director shall be responsible for the integrity of data and statistics and shall protect
against improper or illegal use or disclosure. The Director shall report to the Attorney General through the Assistant
Attorney General. The Director shall not engage in any other employment than that of serving as Director; nor shall the
Director hold any office in, or act in any capacity for, any organization, agency, or institution with which the Bureau
makes any contract or other arrangement under this Act.
(c) Duties and functions of Bureau
The Bureau is authorized to(1) make grants to, or enter into cooperative agreements or contracts with public agencies, institutions of higher
education, private organizations, or private individuals for purposes related to this subchapter; grants shall be made
subject to continuing compliance with standards for gathering justice statistics set forth in rules and regulations
promulgated by the Director;
(2) collect and analyze information concerning criminal victimization, including crimes against the elderly, and civil
disputes;
(3) collect and analyze data that will serve as a continuous and comparable national social indication of the
prevalence, incidence, rates, extent, distribution, and attributes of crime, juvenile delinquency, civil disputes, and
other statistical factors related to crime, civil disputes, and juvenile delinquency, in support of national, State, tribal,
and local justice policy and decisionmaking;
(4) collect and analyze statistical information, concerning the operations of the criminal justice system at the
Federal, State, tribal, and local levels;
(5) collect and analyze statistical information concerning the prevalence, incidence, rates, extent, distribution, and
attributes of crime, and juvenile delinquency, at the Federal, State, tribal, and local levels;
(6) analyze the correlates of crime, civil disputes and juvenile delinquency, by the use of statistical information,
about criminal and civil justice systems at the Federal, State, tribal, and local levels, and about the extent,
distribution and attributes of crime, and juvenile delinquency, in the Nation and at the Federal, State, tribal, and local
levels;
(7) compile, collate, analyze, publish, and disseminate uniform national statistics concerning all aspects of criminal
justice and related aspects of civil justice, crime, including crimes against the elderly, juvenile delinquency, criminal
offenders, juvenile delinquents, and civil disputes in the various States and in Indian country;
(8) recommend national standards for justice statistics and for insuring the reliability and validity of justice statistics
supplied pursuant to this chapter;
(9) maintain liaison with the judicial branches of the Federal Government and State and tribal governments in
matters relating to justice statistics, and cooperate with the judicial branch in assuring as much uniformity as feasible
in statistical systems of the executive and judicial branches;
(10) provide information to the President, the Congress, the judiciary, State, tribal, and local governments, and the
general public on justice statistics;
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(11) establish or assist in the establishment of a system to provide State, tribal, and local governments with access
to Federal informational resources useful in the planning, implementation, and evaluation of programs under this Act;
(12) conduct or support research relating to methods of gathering or analyzing justice statistics;
(13) provide for the development of justice information systems programs and assistance to the States, Indian
tribes, and units of local government relating to collection, analysis, or dissemination of justice statistics;
(14) develop and maintain a data processing capability to support the collection, aggregation, analysis and
dissemination of information on the incidence of crime and the operation of the criminal justice system;
(15) collect, analyze and disseminate comprehensive Federal justice transaction statistics (including statistics on
issues of Federal justice interest such as public fraud and high technology crime) and to provide technical assistance
to and work jointly with other Federal agencies to improve the availability and quality of Federal justice data;
(16) provide for the collection, compilation, analysis, publication and dissemination of information and statistics
about the prevalence, incidence, rates, extent, distribution and attributes of drug offenses, drug related offenses and
drug dependent offenders and further provide for the establishment of a national clearinghouse to maintain and
update a comprehensive and timely data base on all criminal justice aspects of the drug crisis and to disseminate
such information;
(17) provide for the collection, analysis, dissemination and publication of statistics on the condition and progress of
drug control activities at the Federal, State, tribal, and local levels with particular attention to programs and
intervention efforts demonstrated to be of value in the overall national anti-drug strategy and to provide for the
establishment of a national clearinghouse for the gathering of data generated by Federal, State, tribal, and local
criminal justice agencies on their drug enforcement activities;
(18) provide for the development and enhancement of State, tribal, and local criminal justice information systems,
and the standardization of data reporting relating to the collection, analysis or dissemination of data and statistics
about drug offenses, drug related offenses, or drug dependent offenders;
(19) provide for improvements in the accuracy, quality, timeliness, immediate accessibility, and integration of State
and tribal criminal history and related records, support the development and enhancement of national systems of
criminal history and related records including the National Instant Criminal Background Check System, the National
Incident-Based Reporting System, and the records of the National Crime Information Center, facilitate State and
tribal participation in national records and information systems, and support statistical research for critical analysis of
the improvement and utilization of criminal history records;
(20) maintain liaison with State, tribal, and local governments and governments of other nations concerning justice
statistics;
(21) cooperate in and participate with national and international organizations in the development of uniform
justice statistics;
(22) ensure conformance with security and privacy requirement of section 10231 of this title and identify, analyze,
and participate in the development and implementation of privacy, security and information policies which impact on
Federal, tribal, and State criminal justice operations and related statistical activities; and
(23) exercise the powers and functions set out in subchapter VII.
(d) Justice statistical collection, analysis, and dissemination
(1) In general
To ensure that all justice statistical collection, analysis, and dissemination is carried out in a coordinated manner,
the Director is authorized to(A) utilize, with their consent, the services, equipment, records, personnel, information, and facilities of other
Federal, State, local, and private agencies and instrumentalities with or without reimbursement therefor, and to
enter into agreements with such agencies and instrumentalities for purposes of data collection and analysis;
(B) confer and cooperate with State, municipal, and other local agencies;
(C) request such information, data, and reports from any Federal agency as may be required to carry out the
purposes of this chapter;
(D) seek the cooperation of the judicial branch of the Federal Government in gathering data from criminal justice
records;
(E) encourage replication, coordination and sharing among justice agencies regarding information systems,
information policy, and data; and
(F) confer and cooperate with Federal statistical agencies as needed to carry out the purposes of this
subchapter, including by entering into cooperative data sharing agreements in conformity with all laws and
regulations applicable to the disclosure and use of data.
(2) Consultation with Indian tribes
The Director, acting jointly with the Assistant Secretary for Indian Affairs (acting through the Office of Justice
Services) and the Director of the Federal Bureau of Investigation, shall work with Indian tribes and tribal law
enforcement agencies to establish and implement such tribal data collection systems as the Director determines to
be necessary to achieve the purposes of this section.
(e) Furnishing of information, data, or reports by Federal agencies
Federal agencies requested to furnish information, data, or reports pursuant to subsection (d)(1)(C) shall provide
such information to the Bureau as is required to carry out the purposes of this section.
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(f) Consultation with representatives of State, tribal, and local government and judiciary
In recommending standards for gathering justice statistics under this section, the Director shall consult with
representatives of State, tribal, and local government, including, where appropriate, representatives of the judiciary.
(g) Reports
Not later than 1 year after July 29, 2010, and annually thereafter, the Director shall submit to Congress a report
describing the data collected and analyzed under this section relating to crimes in Indian country.
(Pub. L. 90–351, title I, §302, as added Pub. L. 96–157, §2, Dec. 27, 1979, 93 Stat. 1176 ; amended Pub. L. 98–473,
title II, §605(b), Oct. 12, 1984, 98 Stat. 2079 ; Pub. L. 100–690, title VI, §6092(a), Nov. 18, 1988, 102 Stat. 4339 ; Pub.
L. 103–322, title XXXIII, §330001(h)(2), Sept. 13, 1994, 108 Stat. 2139 ; Pub. L. 109–162, title XI, §1115(a), Jan. 5,
2006, 119 Stat. 3103 ; Pub. L. 111–211, title II, §251(b), July 29, 2010, 124 Stat. 2297 ; Pub. L. 112–166, §2(h)(1), Aug.
10, 2012, 126 Stat. 1285 .)

REFERENCES IN TEXT
This Act, referred to in subsecs. (b) and (c)(11), is Pub. L. 90–351, June 19, 1968, 82 Stat. 197 , known as
the Omnibus Crime Control and Safe Streets Act of 1968. For complete classification of this Act to the
Code, see Short Title of 1968 Act note set out under section 10101 of this title and Tables.

CODIFICATION
Section was formerly classified to section 3732 of Title 42, The Public Health and Welfare, prior to
editorial reclassification and renumbering as this section.

PRIOR PROVISIONS
A prior section 302 of Pub. L. 90–351, title I, June 19, 1968, 82 Stat. 200 ; Pub. L. 93–83, §2, Aug. 6, 1973,
87 Stat. 201 ; Pub. L. 94–503, title I, §110, Oct. 15, 1976, 90 Stat. 2412 , related to establishment of State

planning agencies to develop comprehensive State plans for grants for law enforcement and criminal
justice purposes, prior to the general amendment of this chapter by Pub. L. 96–157.

AMENDMENTS
2012-Subsec. (b). Pub. L. 112–166 struck out ", by and with the advice and consent of the Senate" before
period at end of first sentence.
2010-Subsec. (c)(3) to (6). Pub. L. 111–211, §251(b)(1)(A), inserted "tribal," after "State," wherever
appearing.
Subsec. (c)(7). Pub. L. 111–211, §251(b)(1)(B), inserted "and in Indian country" after "States".
Subsec. (c)(9). Pub. L. 111–211, §251(b)(1)(C), substituted "Federal Government and State and tribal
governments" for "Federal and State Governments".
Subsec. (c)(10), (11). Pub. L. 111–211, §251(b)(1)(D), inserted ", tribal," after "State".
Subsec. (c)(13). Pub. L. 111–211, §251(b)(1)(E), inserted ", Indian tribes," after "States".
Subsec. (c)(17). Pub. L. 111–211, §251(b)(1)(F), substituted "activities at the Federal, State, tribal, and
local" for "activities at the Federal, State and local" and "generated by Federal, State, tribal, and local" for
"generated by Federal, State, and local".
Subsec. (c)(18). Pub. L. 111–211, §251(b)(1)(G), substituted "State, tribal, and local" for "State and
local".
Subsec. (c)(19). Pub. L. 111–211, §251(b)(1)(H), inserted "and tribal" after "State" in two places.
Subsec. (c)(20). Pub. L. 111–211, §251(b)(1)(I), inserted ", tribal," after "State".
Subsec. (c)(22). Pub. L. 111–211, §251(b)(1)(J), inserted ", tribal," after "Federal".
Subsec. (d). Pub. L. 111–211, §251(b)(2), designated existing provisions as par. (1), inserted par. (1)
heading, substituted "To ensure" for "To insure", redesignated former pars. (1) to (6) as subpars. (A) to
(F), respectively, of par. (1), realigned margins, and added par. (2).
Subsec. (e). Pub. L. 111–211, §251(b)(3), substituted "subsection (d)(1)(C)" for "subsection (d)(3)".
Subsec. (f). Pub. L. 111–211, §251(b)(4)(B), inserted ", tribal," after "State".
Pub. L. 111–211, §251(b)(4)(A), which directed insertion of ", tribal," after "State" in heading, was
executed editorially but could not be executed in original because heading had been editorially supplied.
Subsec. (g). Pub. L. 111–211, §251(b)(5), added subsec. (g).
2006-Subsec. (b). Pub. L. 109–162, §1115(a)(1), inserted after third sentence "The Director shall be
responsible for the integrity of data and statistics and shall protect against improper or illegal use or
disclosure."
Subsec. (c)(19). Pub. L. 109–162, §1115(a)(2), amended par. (19) generally. Prior to amendment, par.
(19) read as follows: "provide for research and improvements in the accuracy, completeness, and
inclusiveness of criminal history record information, information systems, arrest warrant, and stolen
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vehicle record information and information systems and support research concerning the accuracy,
completeness, and inclusiveness of other criminal justice record information;".
Subsec. (d)(6). Pub. L. 109–162, §1115(a)(3), added par. (6).
1994-Subsec. (c)(19). Pub. L. 103–322 substituted a semicolon for period at end.
1988-Subsec. (c)(16) to (23). Pub. L. 100–690 added pars. (16) to (19) and redesignated former pars.
(16) to (19) as (20) to (23), respectively.
1984-Subsec. (b). Pub. L. 98–473, §605(b)(1), inserted provision requiring Director to report to Attorney
General through Assistant Attorney General.
Subsec. (c)(13). Pub. L. 98–473, §605(b)(2)(A), (C), added par. (13) and struck out former par. (13)
relating to provision of financial and technical assistance to States and units of local government relating
to collection, analysis, or dissemination of justice statistics.
Subsec. (c)(14), (15). Pub. L. 98–473, §605(b)(2)(C), added pars. (14) and (15). Former pars. (14) and
(15) redesignated (16) and (17), respectively.
Subsec. (c)(16). Pub. L. 98–473, §605(b)(2)(A), (B), redesignated par. (14) as (16) and struck out former
par. (16) relating to insuring conformance with security and privacy regulations issued under section 10231
of this title.
Subsec. (c)(17). Pub. L. 98–473, §605(b)(2)(B), redesignated par. (15) as (17). Former par. (17)
redesignated (19).
Subsec. (c)(18). Pub. L. 98–473, §605(b)(2)(D), added par. (18).
Subsec. (c)(19). Pub. L. 98–473, §605(b)(2)(B), redesignated former par. (17) as (19).
Subsec. (d)(1). Pub. L. 98–473, §605(b)(3)(A), inserted ", and to enter into agreements with such
agencies and instrumentalities for purposes of data collection and analysis".
Subsec. (d)(5). Pub. L. 98–473, §605(b)(3)(B)–(D), added par. (5).

EFFECTIVE DATE OF 2012 AMENDMENT
Amendment by Pub. L. 112–166 effective 60 days after Aug. 10, 2012, and applicable to appointments
made on and after that effective date, including any nomination pending in the Senate on that date, see
section 6(a) of Pub. L. 112–166, set out as a note under section 113 of Title 6, Domestic Security.

EFFECTIVE DATE OF 1984 AMENDMENT
Amendment by Pub. L. 98–473 effective Oct. 12, 1984, see section 609AA(a) of Pub. L. 98–473, set out
as an Effective Date note under section 10101 of this title.

CONSTRUCTION OF 2010 AMENDMENT
Pub. L. 111–211, title II, §251(c), July 29, 2010, 124 Stat. 2298 , provided that: "Nothing in this section
[amending this section and section 41507 of this title] or any amendment made by this section"(1) allows the grant to be made to, or used by, an entity for law enforcement activities that the
entity lacks jurisdiction to perform; or
"(2) has any effect other than to authorize, award, or deny a grant of funds to a federally
recognized Indian tribe for the purposes described in the relevant grant program."
[For definition of "Indian tribe" as used in section 251(c) of Pub. L. 111–211, set out above, see section
203(a) of Pub. L. 111–211, set out as a note under section 2801 of Title 25, Indians.]

INCLUSION OF HONOR VIOLENCE IN NATIONAL CRIME VICTIMIZATION SURVEY
Pub. L. 113–235, div. B, title II, Dec. 16, 2014, 128 Stat. 2191 , provided in part: "That beginning not later
than 2 years after the date of enactment of this Act [div. B of Pub. L. 113–235, Dec. 16, 2014], as part of
each National Crime Victimization Survey, the Attorney General shall include statistics relating to honor
violence".

STUDY OF CRIMES AGAINST SENIORS
Pub. L. 106–534, §5, Nov. 22, 2000, 114 Stat. 2557 , provided that:
"(a) IN GENERAL.-The Attorney General shall conduct a study relating to crimes against seniors, in order

to assist in developing new strategies to prevent and otherwise reduce the incidence of those crimes.
"(b) ISSUES ADDRESSED.-The study conducted under this section shall include an analysis of"(1) the nature and type of crimes perpetrated against seniors, with special focus on"(A) the most common types of crimes that affect seniors;
"(B) the nature and extent of telemarketing, sweepstakes, and repair fraud against seniors;
and
"(C) the nature and extent of financial and material fraud targeted at seniors;
"(2) the risk factors associated with seniors who have been victimized;

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"(3) the manner in which the Federal and State criminal justice systems respond to crimes against
seniors;
"(4) the feasibility of States establishing and maintaining a centralized computer database on the
incidence of crimes against seniors that will promote the uniform identification and reporting of such
crimes;
"(5) the effectiveness of damage awards in court actions and other means by which seniors
receive reimbursement and other damages after fraud has been established; and
"(6) other effective ways to prevent or reduce the occurrence of crimes against seniors."

INCLUSION OF SENIORS IN NATIONAL CRIME VICTIMIZATION SURVEY
Pub. L. 106–534, §6, Nov. 22, 2000, 114 Stat. 2557 , provided that: "Beginning not later than 2 years after
the date of enactment of this Act [Nov. 22, 2000], as part of each National Crime Victimization Survey, the
Attorney General shall include statistics relating to"(1) crimes targeting or disproportionately affecting seniors;
"(2) crime risk factors for seniors, including the times and locations at which crimes victimizing
seniors are most likely to occur; and
"(3) specific characteristics of the victims of crimes who are seniors, including age, gender, race or
ethnicity, and socioeconomic status."

CRIME VICTIMS WITH DISABILITIES AWARENESS
Pub. L. 105–301, Oct. 27, 1998, 112 Stat. 2838 , as amended by Pub. L. 106–402, title IV, §401(b)(10), Oct.
30, 2000, 114 Stat. 1739 , provided that:

"SECTION 1. SHORT TITLE.
"This Act may be cited as the 'Crime Victims With Disabilities Awareness Act'.
"SEC. 2. FINDINGS; PURPOSES.
"(a) FINDINGS.-Congress finds that"(1) although research conducted abroad demonstrates that individuals with developmental
disabilities are at a 4 to 10 times higher risk of becoming crime victims than those without disabilities,
there have been no significant studies on this subject conducted in the United States;
"(2) in fact, the National Crime Victim's Survey, conducted annually by the Bureau of Justice
Statistics of the Department of Justice, does not specifically collect data relating to crimes against
individuals with developmental disabilities;
"(3) studies in Canada, Australia, and Great Britain consistently show that victims with
developmental disabilities suffer repeated victimization because so few of the crimes against them are
reported, and even when they are, there is sometimes a reluctance by police, prosecutors, and judges
to rely on the testimony of a disabled individual, making individuals with developmental disabilities a
target for criminal predators;
"(4) research in the United States needs to be done to"(A) understand the nature and extent of crimes against individuals with developmental
disabilities;
"(B) describe the manner in which the justice system responds to crimes against individuals
with developmental disabilities; and
"(C) identify programs, policies, or laws that hold promises for making the justice system more
responsive to crimes against individuals with developmental disabilities; and
"(5) the National Academy of Science Committee on Law and Justice of the National Research
Council is a premier research institution with unique experience in developing seminal, multidisciplinary
studies to establish a strong research base from which to make public policy.
"(b) PURPOSES.-The purposes of this Act are"(1) to increase public awareness of the plight of victims of crime who are individuals with
developmental disabilities;
"(2) to collect data to measure the extent of the problem of crimes against individuals with
developmental disabilities; and
"(3) to develop a basis to find new strategies to address the safety and justice needs of victims of
crime who are individuals with developmental disabilities.
"SEC. 3. DEFINITION OF DEVELOPMENTAL DISABILITY.
"In this Act, the term 'developmental disability' has the meaning given the term in section 102 of the
Developmental Disabilities Assistance and Bill of Rights Act of 2000 [42 U.S.C. 15002].
"SEC. 4. STUDY.
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"(a) IN GENERAL.-The Attorney General shall conduct a study to increase knowledge and information
about crimes against individuals with developmental disabilities that will be useful in developing new
strategies to reduce the incidence of crimes against those individuals.
"(b) ISSUES ADDRESSED.-The study conducted under this section shall address such issues as"(1) the nature and extent of crimes against individuals with developmental disabilities;
"(2) the risk factors associated with victimization of individuals with developmental disabilities;
"(3) the manner in which the justice system responds to crimes against individuals with
developmental disabilities; and
"(4) the means by which States may establish and maintain a centralized computer database on
the incidence of crimes against individuals with disabilities within a State.
"(c) NATIONAL ACADEMY OF SCIENCES.-In carrying out this section, the Attorney General shall consider
contracting with the Committee on Law and Justice of the National Research Council of the National
Academy of Sciences to provide research for the study conducted under this section.
"(d) REPORT.-Not later than 18 months after the date of enactment of this Act [Oct. 27, 1998], the
Attorney General shall submit to the Committees on the Judiciary of the Senate and the House of
Representatives a report describing the results of the study conducted under this section.
"SEC. 5. NATIONAL CRIME VICTIM'S SURVEY.
"Not later than 2 years after the date of enactment of this Act, as part of each National Crime Victim's
Survey, the Attorney General shall include statistics relating to"(1) the nature of crimes against individuals with developmental disabilities; and
"(2) the specific characteristics of the victims of those crimes."

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Attachment 2

VICTIMS WITH DISABILITIES IN HOMELESS SHELTERS PILOT SURVEY

SURVEY INSTRUMENT AND INTERVIEW PROTOCOL

06/27/18

1

Interviewer to administer consent form.
After consent is obtained…
Interviewer:
As I mentioned earlier, this survey is in two parts.
Part 1 focuses on gathering general information about the shelter, such as shelter characteristics, the services
provided to clients, types of victimization and disabilities recorded in client files, and procedures for record
keeping and reporting.
Part 2 asks about one client with a disability that stayed in the shelter in the past 30 days. If a client with a
disability cannot be identified, Part 2 asks about one client who experienced a criminal victimization prior to their
shelter stay.
In Part 2, we will ask you to think about a specific client in your caseload (or in the shelter if R doesn’t have a
caseload). We will be asking questions about:
•
•
•

The client characteristics such as age, gender, race/ethnicity;
The type of victimization experienced by the client prior to their shelter stay; and
Service needs of the client

Note, we will not ask you about the client’s name or other identifying information about your client.
This section is best completed by someone who knows about the experiences of individual clients, often times a
case manager. Do you think you would be able to complete this section of the survey?
•

If yes…
o Great! Let’s start the interview.

•

If no…
o Is there someone from the shelter, like a case worker or a program manager, who might be able
to complete Part 2 of the survey?
 Ask for the staff name and contact information
 Let R know that you will reach out to the staff and schedule a call with them to complete
Part 2
o

When contact info is obtained:
 Great! We’ll complete Part 1 of the survey today. Let’s begin…

2

PART 1: ADMINISTRATORS RESPOND TO THIS SECTION
What is your name, address, telephone number, and email address?
INTERVIEWER NOTE: IF YOU HAVE THE INFORMATION, JUST VERIFY THE ACCURACY.
____________
Prefix

___________________________________________________________________
Name

___________________________________________________________________________________
Job Title
( |___|___|___| ) |___|___|___| - |___|___|___|___|
Telephone number
__________________________________________@________________________________________
Email

What is the name and address of the shelter? What is the phone number, agency email address and website?
INTERVIEWER NOTE: IF YOU HAVE THE INFORMATION, JUST VERIFY ITS ACCURACY.
___________________________________________________________________________________
Shelter Name
____________________________________________________________________________________
Address
________________________________
City

___________________
State

___________________
ZIP

( |___|___|___| ) |___|___|___| - |___|___|___|___|
Main business phone number
___________________________________________________ @ ______________________________
Agency email address
____________________________________________________________________________________
Agency website

3

A. Shelter Characteristics

Now, I am going to ask you a few questions about the shelter.
A1.

What year was this shelter established?
|___|___|___|___|
DON’T KNOW......................................................

A2.

A3.

-8

How is this shelter set up? Is it . . . .?
YES

NO

Facility-based
Beds, including cots or mats, located in a residential
homeless assistance facility dedicated for use by persons
who are homeless ...............................................................

1

2

Voucher
Beds located in a hotel or motel and made available by the
homeless assistance project through vouchers or other
forms of payment.................................................................

1

2

Other
Beds located in a church or other facility not dedicated for
use by persons who are homeless......................................

1

2

Some shelters serve a target population, such as veterans, families, youth, women, and men. Does your
shelter serve a target population?

Note to Interviewer: ENTER ONLY ONE RESPONSE.

Domestic violence victims ………………………..

1

IF YES, screen out of survey. Go to end.
Veterans …………………………………………....

2

Families ...............................................................

3

Youth under the age of 18 ...................................

4

Women ................................................................

5

Men......................................................................

6

Other....................................................................

8

(SPECIFY) _____________________________
Not applicable – Shelter does not have a target
population …………………………………………
Note to interviewer: If R selected more than one
above then shelter doesn’t have a target population

4

9

A4.

What is the total number of beds available year round including seasonal beds or beds available for a
specific part of the year but not the entire year?
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

A5.

Of the [TOTAL NUMBER OF BEDS] reported in the previous question, how many are seasonal beds.
That means beds available for a specific part of the year but not the entire year)? Estimates are
acceptable.
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

A6.

In the past 30 days, how many clients spent at least one night in this shelter?
|___|___|___|___|
DON’T KNOW......................................................

A7.

-8

Does this shelter follow up with clients after they leave this shelter?
YES ......................................................................
NO .......................................................................
DON’T KNOW......................................................

1
2
-8

B. Services

B1.

Think about all services this shelter provided to clients in the past 30 days. For each of the following
services, please tell me in which of these ways the service is provided: in-house, through a vendor or
contract with other agencies, and as referral to other agencies. If the service is not provided, just let me
know..

Note to Interviewer:
MARK “NO” IF THE SERVICE IS NOT PROVIDED.
*Volunteers or volunteer organizations who come into the shelter to provide services on a regular basis
are considered “Vendors.”

5

a. Mental health services ...............

YES, SERVICE WAS PROVIDED
Vendor
(contract
Referral to
w/other
other
In-house
agency)
agency
1
2
3

NO, NOT
PROVIDED
4

DON’T
KNOW
-8

b. Crisis counseling .......................

1

2

3

4

-8

c. Safety services; for example,
safety planning; witness
protection; self-defense .............

1

2

3

4

-8

d. Medical services ........................

1

2

3

4

-8

e. Civil legal aid .............................

1

2

3

4

-8

Assistance for applying for
benefits ......................................

1

2

3

4

-8

g. Employment services ................

1

2

3

4

-8

h. Vocational training .....................

1

2

3

4

-8

i.

Monetary assistance..................

1

2

3

4

-8

j.

Other ..........................................
(SPECIFY) ________________

1

2

3

4

-8

f.

B2.

In the past 30 days, did this shelter work with any of the following types of organizations to provide clients
with services or referrals to services?

a. Law enforcement ...........................................
b. Hospitals, clinics, or other medical service
providers........................................................
c. Mental health organizations ………………….
d. Substance abuse organizations ………………..
e. Legal aid organizations .................................
f. Victim service organizations..........................
g. Advocacy organizations ................................
h. Other organizations .......................................
(SPECIFY)__________________________

YES
1

NO
2

DON’T
KNOW
-8

1
1
1
1
1
1
1

2
2
2
2
2
2
2

-8
-8
-8
-8
-8
-8
-8

C. Record Keeping and Reporting: Victimization

Now, I am going to read a list of different types of victimizations that clients might experience. The focus of this
question is on whether the shelter documents victimization experiences in a case management system or in some
other way that allows the you to generate a report on the number of clients who experienced the victimization.
C1. Specifically, when the shelter learns that a client has been a victim of the following crimes, is this documented
in a way that enables you to count the total number of victims? You can respond yes, no, or don’t know.

6

Note to interviewer:
If R asks to clarify: For example, would you be able to easily generate a report about the number
of clients who experienced victimization prior to their shelter stay?
Follow example use starting phrase in a and b when going through the list of victimization types.

Yes

No

a. For example, is domestic violence/dating violence documented
in client files so that your shelter could report on the number of
identified victims? .................................. ……

1

2

b. How about rape/sexual assault against adults?......................

1

2

c. Sexual abuse/ sexual assault against children (or committed in
childhood against an adult client)? ……………………………

1

2

d. Physical assault, abuse, or neglect against adults including
elder abuse ………… ....................................

1

2

e. Physical assault, abuse, or neglect against children (or
committed in childhood against an adult
client)?………………………………………….

1

2

1

2

g. Human trafficking .......................……………

1

2

h. Survivors of homicide victims ........................

1

2

i.

Identity theft or financial fraud .......................

1

2

j.

Motor vehicle theft .........................................

1

2

k.

Other crimes (Specify) .................................

1

2

f.

Other physical assault not captured above including community
violence, gun violence, stabbings, etc. ……………………..

If response to all items is NO or DON’T KNOW, skip to Section D.
C2.

You indicated that this shelter documents certain types of victimizations. In the past 30 days, have you
documented [type of victimization from C1] in any client files?

[Note to Programming: Only items in C1 that R responded to as “Yes” will show up here].
Yes

No

a. domestic violence/dating violence ……………………………...

1

2

b. rape/sexual assault against adults?......................

1

2

c. Sexual abuse/ sexual assault against children (or committed in
childhood against an adult client)? ……………………………

1

2

d. Physical assault, abuse, or neglect against adults including
elder abuse ………… ...................................

1

2

e. Physical assault, abuse, or neglect against children (or
committed in childhood against an adult
client)?………………………………………….

1

2

7

f.

Other physical assault not captured above including community
violence, gun violence, stabbings, etc. ……………………

1

2

g. Human trafficking .......................……………

1

2

h. Survivors of homicide victims ........................

1

2

i.

Identity theft or financial fraud .......................

1

2

j.

Motor vehicle theft .........................................

1

2

k.

Other crimes (Specify) .................................

1

2

C3.

In the past 30 days, how many of shelter clients had information about victimization documented in their
files?
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

D. Shelter Resources for Victims

D1.

Including contractual workers, how many paid staff currently work at this emergency shelter full-time (35
hours or more/week)? Count each person only once. Enter 0 if there are no paid full-time staff. Estimates
are acceptable.
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

D2.

Including contractual workers, how many paid staff currently work at this emergency shelter part-time
(less than 35 hours/week)? Count each person only once. Enter 0 if there are no paid full-time staff.
Estimates are acceptable.
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

We are also interested in whether shelters have staff who specialize in working with clients who are victims.
D3.

How many current paid staff in this shelter specialize in working with clients who are victims? Estimates
are acceptable.
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

D4.

Does this shelter currently have funding specifically to serve clients who are victims?
YES ......................................................................
NO .......................................................................
DON’T KNOW......................................................

8

1
2
-8

IF YES, does your shelter currently have any of the following types of funding to serve victims?

YES

NO

DON’T
KNOW

a. U.S. Office for Victims of Crime (OVC) funding and/or
Victims of Crime Act (VOCA) funding ...............................

1

2

-8

b. Services, Training, Officers, and Prosecutors (STOP) grant
..........................................................................................

1

2

-8

c. Sexual Assault Services Program (SASP) funding ..........

1

2

-8

d. Other Office on Violence Against Women (OVW) funding,
including all other grants funded under the Violence Against
Women Act (VAWA)..........................................................

1

2

-8

1
1

2
2

-8
-8

g. State government funding not state disbursement of federal
grant ..................................................................................

1

2

-8

h. Local government funding .................................................

1

2

-8

i.

Tribal government funding ................................................

1

2

-8

j.

Other funding sources; for example, foundations, corporate
funding, individual donations, insurance reimbursements,
etc......................................................................................
(SPECIFY)____________________________________

1

2

-8

e. Family Violence Prevention Services Act (FVPSA) funding
..........................................................................................
f.

Other federal funding ........................................................
(SPECIFY)____________________________________

E. Record Keeping and Reporting: Disabilities

Of the clients who stayed in this shelter for at least one night in the past 30 days, now think only about the
clients with disabilities. For this survey, disabilities are defined as the following:
Note to Interviewer:
PLEASE READ DEFINITIONS ALOUD.
•
•
•
•
•
•

E1.

Hearing difficulty. Deaf or having serious difficulty hearing.
Vision difficulty. Blind or having serious difficulty seeing, even when wearing glasses.
Cognitive difficulty. Because of a physical, mental, or emotional problem, having difficulty remembering,
concentrating, or making decisions.
Ambulatory difficulty. Having serious difficulty walking or climbing stairs.
Self-care difficulty. Having difficulty bathing or dressing.
Independent living difficulty. Because of a physical, mental, or emotional problem, having difficulty doing
errands alone such as visiting a doctor’s office or shopping.

In the past 30 days, did this shelter serve any clients that were known or suspected to have a disability?
YES ......................................................................
NO .......................................................................
DON’T KNOW......................................................

9

1
2
-8

E1a.

For each type of disabilities I read, please tell me the primary way the shelter determines a client
has a disability?

Note to Interviewer: SELECT ONLY ONE RESPONSE PER DISABILITY.

Intake/Screening
Assessment

Disclosed by client at
a later time during
shelter stay

Other
(please specific)

Hearing difficulty
Vision difficulty
Cognitive difficulty
Ambulatory difficulty
Self-care difficulty
Independent living difficulty

[Note to Programming: Skip E1b and E1c, if E1a is “NO.”]
E1b.
Of those clients in this shelter who stayed at least one night during the past 30 days, how many
were known or suspected to have a disability? Estimates are acceptable.
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

E1c.

Of the [ENTER NUMBER FROM E1b] who had a disability, how many clients were documented
as having a disability in their client file?
|___|___|___|___|
 DISABILITY IS NOT DOCUMENTED  SKIP TO E2

E1d.

What is the primary method the shelter uses to document disabilities in the client files?

Note to Interviewer: ENTER ONLY ONE ANSWER.

a. An internal database or case
management system ..............................
b. Paper systems or paper tracking ...........
c. Other ......................................................
(SPECIFY) ______________________

E2.

1
2
3

Does this shelter have any programs designed specifically to serve clients with disabilities who have
been victims of crime or abuse?
YES ......................................................................
NO .......................................................................
DON’T KNOW......................................................

10

1
2
-8

If yes, briefly describe the program(s): ___________________________________________
____________________________________________________________________________

If the same participant is completing Part 2: You have completed the first part of the survey and we will now
begin the second part. [Note to programming: However, if R’s response to E1 is “NO,” then R has
completed the survey. Skip Part 2].
If a different staff is completing Part 2: You have completed the survey. Thank you very much for participating
in this important study..

11

PART 2: ADMINISTRATORS OR CASE MANAGERS
RESPOND TO THIS SECTION
Note to Interviewer:
If same participant indicates that he/she will be able to complete Part 2, proceed to the next page.
WHEN A SECOND RESPONDENT ANSWERS PART 2, ADMINISTER THE INFORMED CONSENT TO THE
SECOND PERSON.
Note to programming: Load information from Part 1 if the same participant.
Please tell me your name, job title, telephone number, and email.
Note to Interviewer::
IF YOU HAVE THE INFORMATION, JUST VERIFY ITS ACCURACY.

____________
Prefix

___________________________________________________________________
Name

___________________________________________________________________________________
Job Title
( |___|___|___| ) |___|___|___| - |___|___|___|___|
Telephone number
__________________________________________@________________________________________
Email

What was the number of clients in your caseload during the past 30 days:

12

|___|___|___|___|

A. Client Characteristics
If same participant as Part 1: Now, I’m going to ask you about a specific client in your caseload (or in the shelter
if R doesn’t have a caseload)…
If a different participant: In this interview, I’m going to ask you to think about clients in your caseload (or in the
shelter if R doesn’t have a caseload)…
Of the clients in your caseload/this shelter in the past 30 days, think only about the clients with disabilities.
For this survey, disabilities are defined as the following:
NOTE TO INTERVIEWER:
PLEASE READ THE DEFINITIONS ALOUD.
•
•
•

Hearing difficulty. Deaf or having serious difficulty hearing.
Vision difficulty. Blind or having serious difficulty seeing, even when wearing glasses.
Cognitive difficulty. Because of a physical, mental, or emotional problem, having difficulty remembering,
concentrating, or making decisions.
Ambulatory difficulty. Having serious difficulty walking or climbing stairs.
Self-care difficulty. Having difficulty bathing or dressing.
Independent living difficulty. Because of a physical, mental, or emotional problem, having difficulty doing
errands alone such as visiting a doctor’s office or shopping.

•
•
•

[Note to Programming: If same participant is completing the survey, load response from Part 1, E1b. A1
below is similar to Part 1, E1b]
A1.
Of the clients in your caseload/the shelter in the past 30 days, how many were known or suspected to
have a disability?
|___|___|___|___|
 RESPONSE PROVIDED IN AN ESTIMATE.
If zero and C3>1, got to A1a.
If zero and C3=0. Thank you very much for participating in this study.
If >zero, move to disability instruction
A1a.

In the first part of the survey, it was reported that [fill from C3] clients in the past 30 days had information
about experiences with crime victimization documented in their files. For the remainder of the survey,
think about the one client with a documented victimization who stayed the most nights in this shelter in
the past 30 days.  go to A2

Disability Instruction
Among these clients with a disability, think about the one client who stayed the most nights in this shelter in the
past 30 days.
Note to Interviewer:
If the person says there are two or more people with disabilities who stayed the same amount of time
in the shelter, instruct them to select one.

A2.

How many total nights did the client stay in this shelter in the past 30 days?

13

|___|___|

A3.

What was the age of the client?
|___|___|

A4.

What was the client’s gender?
MALE ...................................................................
FEMALE ..............................................................
TRANSGENDER .................................................
DON’T KNOW......................................................

A5.

Was the client of Hispanic origin?
YES ......................................................................
NO .......................................................................
DON’T KNOW......................................................

A6.

1
2
5
-8

1
2
-8

What was the client’s race?
YES
1
1
1
1
1
1

White ...................................................................
Black or African American ...................................
American Indian or Alaska Native .......................
Asian....................................................................
Native Hawaiian or Other Pacific Islander ..........
Other....................................................................
(SPECIFY) _____________________________

A7.

NO
2
2
2
2
2
2

DON’T
KNOW
-8
-8
-8
-8
-8
-8

Was the client a veteran?
YES ......................................................................
NO .......................................................................
DON’T KNOW......................................................

1
2
-8

If A1=0, skip to B1.
A8.
Was the client known or suspected to have had any of the following disabilities?

a. Hearing difficulty: Deaf or has serious difficulty hearing .........

YES
1

NO
2

DON’T
KNOW
-8

b. Vision difficulty: Blind or has serious difficulty seeing, even
when wearing glasses .............................................................

1

2

-8

c. Cognitive difficulty: Because of a physical, mental, or
emotional problem, has difficulty remembering,
concentrating, or making decisions .........................................

1

2

-8

d. Ambulatory difficulty: Has serious difficulty walking or
climbing stairs ..........................................................................

1

2

-8

e. Self-care difficulty: Has difficulty bathing or dressing. ............

1

2

-8

14

f.

Independent living difficulty. Because of a physical, mental,
or emotional problem, has difficulty doing errands alone such
as visiting a doctor’s office or shopping...................................

g. Other ........................................................................................
(SPECIFY) _______________________________________

1

2

-8

1

2

-8

B. Type of Victimization Experienced by a Client

For the next questions, please continue to think about the [client with a disability/client who was a crime
victim] who spent the most nights in this shelter in the past 30 days. I am going to read a list of
victimizations and ask you about the client’s experiences with them.
B1.

Did the client experience any of the following types of victimizations prior to their shelter stay?
Yes

No

a. Domestic violence/dating violence ……………………………...

1

2

b. Rape/sexual assault against adults?......................

1

2

c. Sexual abuse/ sexual assault against children (or committed in
childhood against an adult client)? ……………………………

1

2

d. Physical assault, abuse, or neglect against adults including elder abuse
…………………… ..........................................

1

2

e. Physical assault, abuse, or neglect against children (or committed in
childhood against an adult client)?………………………………………….

1

2

1

2

g. Human trafficking .......................……………

1

2

h. Survivors of homicide victims ........................

1

2

i.

Identity theft or financial fraud .......................

1

2

j.

Motor vehicle theft .........................................

1

2

k. Other crimes (Specify) ..................................

1

2

Yes

No

a. Domestic violence/dating violence ……………………………...

1

2

b. Rape/sexual assault against adults?......................

1

2

c. Sexual abuse/ sexual assault against children (or committed in
childhood against an adult client)? ……………………………

1

2

d. Physical assault, abuse, or neglect against adults including elder abuse
……………………. .........................................

1

2

f.

Other physical assault not captured above including community
violence, gun violence, stabbings, etc. ……………………………………

IF RESPONSE TO ANY OF THE ITEMS IS “YES,” GO TO SECTION C.
[Note to Programming: Only ask B2 if NO victimizations reported in B1]
B2.

Was the client screened for any of the following types of victimization?

15

e. Physical assault, abuse, or neglect against children (or committed in
childhood against an adult client)?………………………………………….

1

2

1

2

g. Human trafficking .......................……………

1

2

h. Survivors of homicide victims ........................

1

2

i.

Identity theft or financial fraud .......................

1

2

j.

Motor vehicle theft .........................................

1

2

k. Other crimes (Specify) ..................................

1

2

f.

Other physical assault not captured above including community
violence, gun violence, stabbings, etc. ……………………………………

WHEN B2 IS COMPLETED, GO TO END.

C. Service Needs of One Client with a Disability/Victimization who Experienced a Victimization

Think about the same [client with a disability/client who was a crime victim] who spent the most nights in
this shelter in the past 30 days.
C1.

Did the client need any of the following services as a result of being a victim?

a. Mental health services ..........................................
b. Crisis counseling ...................................................
c. Safety services; for example; safety planning;
witness protection; self-defense ...........................
d. Medical services ...................................................
e. Civil legal aid; for example, protection order ........
f. Assistance for applying for benefits ......................
g. Employment services ............................................
h. Vocational training ................................................
i. Monetary assistance .............................................
j. Other .....................................................................
(SPECIFY) _____________________________

C2.

YES
1
1

NO
2
2

DON’T
KNOW
-8
-8

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

-8
-8
-8
-8
-8
-8
-8
-8

Did the client receive any of the following services through in-house, vendor or contract with other
agencies, and referrals to other agencies specifically to address his/her needs as a victim?

INTERVIEWER NOTE:
MARK NO IF THE SERVICE WAS NOT PROVIDED.

a. Mental health services .....................
b. Crisis counseling ..............................

Inhouse
1
1

16

YES
Vendor
(contract w/
other agency)
2
2

Referral
to other
agency
3
3

NO
4
4

DON’T
KNOW
-8
-8

c. Safety services; for example, safety
planning; witness protection; selfdefense ............................................
d. Medical services ..............................
e. Civil legal aid; for example,
protection orders ..............................
f. Assistance for applying for benefits .
g. Employment services .......................
h. Vocational training ...........................
i. Monetary assistance ........................
j. Other ................................................
(SPECIFY) ___________________

C3.

1
1
1

2
2
2

3
3
3

4
4
4

-8
-8
-8

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

-8
-8
-8
-8
-8

Did this shelter work with any of the following types of organizations to provide services or referrals
specifically to address the client’s needs related to victimization?

a.
b.
c.
d.
e.
f.
g.
h.

Law enforcement ...........................................
Hospitals, clinics or other medical providers .
Mental health organizations ………………….
Substance abuse organizations ……………..
Legal aid organizations .................................
Victim service organizations..........................
Advocacy organizations ………………………
Other organizations .......................................
(SPECIFY)__________________________

YES
1
1
1
1
1
1
1
1

NO
2
2
2
2
2
2
2
2

DON’T
KNOW
-8
-8
-8
-8
-8
-8
-8
-8

We have completed the survey. Thank you very much for participating in this important study!

17

Attachment 3

COGNITIVE TESTING PROTOCOL
FOR:
VICTIMS WITH DISABILITIES IN HOMELESS SHELTERS PILOT SURVEY

DRAFT 5/18/18

1

This survey is in two parts. Part 1 focuses on gathering general information about the shelter, such as
shelter characteristics, the service provided to clients with different needs, types of victimization and
disabilities recorded in client files, and procedures for record keeping and reporting. Part 2 focuses on
experiences with clients who have a disability. We will not ask you about any identifying information about
your clients. If you know about the characteristics of the shelter and the experiences of the clients then I
will ask you the questions in both parts. If you feel it is more appropriate for another person, such as a
case manager, to answer Part 2, please identify a colleague and I will call the appropriate person to finish
the interview.

PART 1: ADMINISTRATORS RESPOND TO THIS
SECTION
What is your name, address, telephone number, and email address?
INTERVIEWER NOTE: IF YOU HAVE THE INFORMATION, JUST VERIFY THE ACCURACY.
____________
Prefix

___________________________________________________________________
Name

___________________________________________________________________________________
Job Title
( |___|___|___| ) |___|___|___| - |___|___|___|___|
Telephone number
__________________________________________@________________________________________
Email

What is the name and address of the shelter? What is the phone number, agency email address and
website?
INTERVIEWER NOTE: IF YOU HAVE THE INFORMATION, JUST VERIFY ITS ACCURACY.
___________________________________________________________________________________
Shelter Name
___________________________________________________________________________________
Address
_______________________________
City

__________________
State

__________________
ZIP

( |___|___|___| ) |___|___|___| - |___|___|___|___|
Main business phone number
___________________________________________________ @ _____________________________
Agency email address
___________________________________________________________________________________
Agency website

2

A. Shelter Characteristics

Now, I am going to ask you a few questions about the shelter.
A1.

What year was this shelter established?
|___|___|___|___|
DON’T KNOW ......................................................

A2.

A3.

-8

How is this shelter set up. Is it . . . .?
YES

NO

Facility-based
Beds, including cots or mats, located in a residential
homeless assistance facility dedicated for use by persons
who are homeless ................................................................

1

2

Voucher
Beds located in a hotel or motel and made available by the
homeless assistance project through vouchers or other
forms of payment .................................................................

1

2

Other
Beds located in a church or other facility not dedicated for
use by persons who are homeless ......................................

1

2

What population(s) does this shelter primarily serve? Does it primarily serve . . . .

INTERVIEWER NOTE: ENTER ONLY ONE RESPONSE.
Domestic violence victims..................................
IF YES, screen out of survey
Families..............................................................
Youth under the age of 18 .................................
Women...............................................................
Men ....................................................................
Other ..................................................................
(SPECIFY) ____________________________

3

1
2
3
4
5
6

A4.

Does this shelter serve clients with specific needs such as…

a.
b.
c.
d.
e.
f.

Domestic violence.........................................
HIV/AIDS ......................................................
Problems with substance abuse ...................
Problems with mental health ........................
Disabilities.....................................................
Re-entry from prison and jail or other needs
related to previous incarceration ..................
g. Problems/ or re-entry from military service ...
h. Human Trafficking . . . . . . . . .. . . . . . . . . . . .
i. Other .............................................................
(SPECIFY) _________________________

A5.

YES
1
1
1
1
1

NO
2
2
2
2
2

DON’T
KNOW
-8
-8
-8
-8
-8

1
1
1
1

2
2
2
2

-8
-8
-8
-8

What is the total number of beds available year round including seasonal beds or beds
available for a specific part of the year but not the entire year?
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

A6.

Of the [TOTAL NUMBER OF BEDS] reported in the previous question, how many are seasonal
beds. That means beds available for a specific part of the year but not the entire year)?
Estimates are acceptable.
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

A7.

In the past 30 days, how many clients spent at least one night in this shelter?
|___|___|___|___|
DON’T KNOW ......................................................

4

-8

A8.

Does this shelter follow up with clients after they leave this shelter?
YES ......................................................................
NO ........................................................................
DON’T KNOW ......................................................

1
2
-8

B. Services
B1.

Think about all services this shelter provided to clients in the past 30 days. For each of the
following services, please tell me in which of these ways the service is provided: in-house, through
a vendor or contract with other agencies, and as referral to other agencies. If you can let me know
the service was not provided.

INTERVIEW NOTE: MARK “NO” IF THE SERVICE IS NOT PROVIDED.

a. Mental health services ...............

YES, SERVICE WAS PROVIDED
Vendor
(contract
Referral to
w/other
other
In-house
agency)
agency
1
2
3

NO, NOT
PROVIDED
4

DON’T
KNOW
-8

b. Crisis counseling ........................

1

2

3

4

-8

c. Safety services; for example,
safety planning; witness
protection; self-defense..............

1

2

3

4

-8

d. Medical services ........................

1

2

3

4

-8

e. Civil legal aid ..............................

1

2

3

4

-8

Assistance for applying for
benefits .......................................

1

2

3

4

-8

g. Employment services .................

1

2

3

4

-8

h. Vocational training .....................

1

2

3

4

-8

i.

Monetary assistance ..................

1

2

3

4

-8

j.

Other ..........................................
(SPECIFY) ________________

1

2

3

4

-8

f.

B2.

In the past 30 days, did this shelter work with any of the following types of organizations to
provide clients with services or referrals to services?

a. Law enforcement ..........................................
b. Hospitals, clinics, or other medical service
providers .......................................................
c. Legal aid organizations .................................
d. Victim service organizations .........................
e. Advocacy organizations ................................
f. Other organizations ......................................
(SPECIFY) _________________________

5

YES
1

NO
2

DON’T
KNOW
-8

1
1
1
1
1

2
2
2
2
2

-8
-8
-8
-8
-8

C. Record Keeping and Reporting: Victimization
Now think about the clients who stayed in this shelter for at least one night in the past 30 days. I am
going to read a list of different types of victimizations and ask you whether any clients experienced them
prior to their shelter stay. You can respond yes, no, or don’t know.

a. Adults molested as children ..........................

C1.
Did any of these clients
experience this
victimization prior to their
shelter stay?
Yes
No
DK
1
2
-8

C2.
Is this type of
victimization typically
documented in client
files?
Yes
No
DK
1
2
-8

b. Child sexual abuse/ sexual assault ...............

1

2

-8

1

2

-8

c. Rape/sexual assault other than sexual
victimizations against children ......................

1

2

-8

1

2

-8

d. Stalking .........................................................

1

2

-8

1

2

-8

e. Child witness of violence...............................

1

2

-8

1

2

-8

f.

Child physical abuse or neglect ....................

1

2

-8

1

2

-8

g. Elder physical abuse .....................................

1

2

-8

1

2

-8

h. Domestic violence/dating violence ................

1

2

-8

1

2

-8

Assault other than domestic/dating violence
or child/elder abuse .......................................

1

2

-8

1

2

-8

Robbery.........................................................

1

2

-8

1

2

-8

k. Human trafficking for labor ...........................

1

2

-8

1

2

-8

l.

Human trafficking for sex ..............................

1

2

-8

1

2

-8

m. Survivors of homicide victims........................

1

2

-8

1

2

-8

n. Witness intimidation ......................................

1

2

-8

1

2

-8

o. DUI/DWI crashes ..........................................

1

2

-8

1

2

-8

p. Identity theft ..................................................

1

2

-8

1

2

-8

q. Financial fraud and exploitation other than
identity theft ...................................................

1

2

-8

1

2

-8

r.

Motor vehicle theft.........................................

1

2

-8

1

2

-8

s. Other property crimes ...................................

1

2

-8

1

2

-8

t.

Hate crimes ...................................................

1

2

-8

1

2

-8

u. Child marriage or forced marriage ................

1

2

-8

1

2

-8

v. Honor related violence (IF NEEDED:
physical violence/ threats/retaliation in the
name of family honor, female genital
mutilation)......................................................

1

2

-8

1

2

-8

i.
j.

If response to all items is NO or DON’T KNOW, skip to Section D.

6

C3.

Thinking about the types of victimizations selected in the last question, how many clients who
stayed in this shelter for at least one night in the past 30 days experienced one or more
victimization prior to their shelter stay?
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

C4.

Of the [ENTER NUMBER FROM C3], how many of these clients did this shelter document the
victimization in the client’s file?
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

D. Shelter Resources for Victims

D1.

How many paid staff currently work at your organization full-time (35 hours or more/week)?
Count each person only once. Enter 0 if there are no paid full-time staff. Include contractual
workers in your counts. Estimates are acceptable.
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

D2.

How many paid staff currently work at your organization part-time (less than 35 hours/week)?
Count each person only once. Enter 0 if there are no paid full-time staff. Include contractual
workers in your counts. Estimates are acceptable.
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

D3.

In the past 30 days, how many paid full-time shelter staff were dedicated full time to providing
support or services for clients who are victims? Estimates are acceptable.
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

D4.

In the past 30 days, how many paid shelter staff spent at least part of their time serving clients
who are victims? Estimates are acceptable.
|___|___|___|___|
 Response provided is an estimate.

7

D5.

Does this shelter currently have funding specifically to serve clients who are victims?
YES ......................................................................
NO ........................................................................
DON’T KNOW ......................................................

1
2
-8

IF YES, does your shelter currently have any of the following types of funding to serve victims?

YES

NO

DON’T
KNOW

a. Victims of Crime Act (VOCA) funding ..............................

1

2

-8

b. Other U.S. Office for Victims of Crime (OVC) funding.....

1

2

-8

c. Services, Training, Officers, and Prosecutors (STOP)
grant .................................................................................

1

2

-8

d. Sexual Assault Services Program (SASP) funding ........

1

2

-8

e. Other Office on Violence Against Women (OVW)
funding, including all other grants funded under the
Violence Against Women Act (VAWA) ............................

1

2

-8

1
1

2
2

-8
-8

h. State government funding not state disbursement of
federal grant.....................................................................

1

2

-8

i.

Local government funding ...............................................

1

2

-8

j.

Tribal government funding ...............................................

1

2

-8

1

2

-8

f.

Family Violence Prevention Services Act (FVPSA)
funding ............................................................................

g. Other federal funding .......................................................
(SPECIFY) ___________________________________

k. Other funding sources; for example, foundations,
corporate funding, individual donations, insurance
reimbursements, etc. .......................................................
(SPECIFY) ___________________________________

8

E. Record Keeping and Reporting: Disabilities

Of the clients who stayed in this shelter for at least one night in the past 30 days, now think only about
the clients with disabilities. For this survey, disabilities are defined as the following:
INTERVIEW NOTE: PLEASE READ DEFINITIONS ALOUD.
•
•
•
•
•
•

E1.

Hearing difficulty. Deaf or having serious difficulty hearing.
Vision difficulty. Blind or having serious difficulty seeing, even when wearing glasses.
Cognitive difficulty. Because of a physical, mental, or emotional problem, having difficulty
remembering, concentrating, or making decisions.
Ambulatory difficulty. Having serious difficulty walking or climbing stairs.
Self-care difficulty. Having difficulty bathing or dressing.
Independent living difficulty. Because of a physical, mental, or emotional problem, having difficulty
doing errands alone such as visiting a doctor’s office or shopping.

In the past 30 days, did this shelter serve any clients that were known or suspected to have a
disability?
YES ......................................................................
NO ........................................................................
DON’T KNOW ......................................................
E1a.

1
2
-8

For each type of disabilities I read, please tell me the primary way the shelter determines
a client has a disability?

INTERVIEWER NOTE: SELECT ONLY ONE RESPONSE PER DISABILITY.

Intake/Screening
Assessment

Disclosed by client at
a later time during
shelter stay

Other
(please specific)

Hearing difficulty
Vision difficulty
Cognitive difficulty
Ambulatory difficulty
Self-care difficulty
Independent living difficulty

E1b.

Of those clients in this shelter who stayed at least one night during the past 30 days, how
many were known or suspected to have a disability? Estimates are acceptable.
|___|___|___|___|
 RESPONSE PROVIDED IS AN ESTIMATE.

9

E1c.

Of the [ENTER NUMBER FROM E1b] who had a disability, how many clients were
documented as having a disability in their client file?
|___|___|___|___|
 DISABILITY IS NOT DOCUMENTED  SKIP TO E2

E1d.

What is the primary method the shelter uses to document disabilities in the client files?

INTERVIEWER NOTE: ENTER ONLY ONE ANSWER.

a. An internal database or case
management system ..............................
b. Paper systems or paper tracking ............
c. Other .......................................................
(SPECIFY) _______________________

E2.

1
2
3

Does this shelter have any programs that serve clients with disabilities who have been
victims of crime or abuse?
YES ......................................................................
NO ........................................................................
DON’T KNOW ......................................................

1
2
-8

If yes, briefly describe the program(s): ____________________________________________
_____________________________________________________________________________

Thank you for completing the administrator’s survey.

10

PART 2: ADMINISTRATORS OR CASE MANAGERS
RESPOND TO THIS SECTION
NOTE TO INTERVIEWER:
WHEN A SECOND RESPONDENT ANSWERS PART 2, ADMINISTER THE INFORMED CONSENT TO
THE SECOND PERSON.
Please tell me your name, job title, telephone number, and email.
INTERVIEWER NOTE:
IF YOU HAVE THE INFORMATION, JUST VERIFY ITS ACCURACY.

____________
Prefix

___________________________________________________________________
Name

___________________________________________________________________________________
Job Title
( |___|___|___| ) |___|___|___| - |___|___|___|___|
Telephone number
__________________________________________@________________________________________
Email

What was the number of clients in your caseload during the past 30 days:

11

|___|___|___|___|

A. Client Characteristics

Of the clients in your caseload in the past 30 days, think only about the clients with disabilities. For
this survey, disabilities are defined as the following:
NOTE TO INTERVIEWER:
PLEASE READ THE DEFINITIONS ALOUD.
•
•
•
•
•
•

A1.

Hearing difficulty. Deaf or having serious difficulty hearing.
Vision difficulty. Blind or having serious difficulty seeing, even when wearing glasses.
Cognitive difficulty. Because of a physical, mental, or emotional problem, having difficulty
remembering, concentrating, or making decisions.
Ambulatory difficulty. Having serious difficulty walking or climbing stairs.
Self-care difficulty. Having difficulty bathing or dressing.
Independent living difficulty. Because of a physical, mental, or emotional problem, having difficulty
doing errands alone such as visiting a doctor’s office or shopping.

Of the clients in your caseload in the past 30 days, how many were known or suspected to have a
disability?
|___|___|___|___|
 RESPONSE PROVIDED IN AN ESTIMATE.
If zero, you have completed this survey. Thank you very much for participating in this
study.

Among these clients with a disability, think about the one client who stayed the most nights in
this shelter in the past 30 days.
A2.

How many total nights did the client stay in this shelter in the past 30 days?
|___|___|

A3.

What was the age of the client?
|___|___|

A4.

What was the client’s gender?
MALE ...................................................................
FEMALE ...............................................................
TRANSGENDER..................................................
DON’T KNOW ......................................................

12

1
2
5
-8

A5.

Was the client of Hispanic origin?
YES ......................................................................
NO ........................................................................
DON’T KNOW ......................................................

A6.

What was the client’s race?

White ...................................................................
Black or African American ..................................
American Indian or Alaska Native ......................
Asian ...................................................................
Native Hawaiian or Other Pacific Islander ..........
Other ...................................................................
(SPECIFY) ____________________________

A7.

YES
1
1
1
1
1
1

NO
2
2
2
2
2
2

DON’T
KNOW
-8
-8
-8
-8
-8
-8

Was the client a veteran?
YES ......................................................................
NO ........................................................................
DON’T KNOW ......................................................

A8.

1
2
-8

1
2
-8

Was the client known or suspected to have had any of the following disabilities?

a. Hearing difficulty: Deaf or has serious difficulty hearing ...

YES
1

NO
2

DON’T
KNOW
-8

b. Vision difficulty: Blind or has serious difficulty seeing,
even when wearing glasses ..............................................

1

2

-8

c. Cognitive difficulty: Because of a physical, mental, or
emotional problem, has difficulty remembering,
concentrating, or making decisions ..................................

1

2

-8

d. Ambulatory difficulty: Has serious difficulty walking or
climbing stairs ...................................................................

1

2

-8

e. Self-care difficulty: Has difficulty bathing or dressing. .....

1

2

-8

1

2

-8

1

2

-8

f.

Independent living difficulty. Because of a physical,
mental, or emotional problem, has difficulty doing
errands alone such as visiting a doctor’s office or
shopping............................................................................

g. Other .................................................................................
(SPECIFY) ____________________________________

13

B. Type of Victimization Experienced by a Client with a Disability

For the next questions, please continue to think about the client with a disability who spent the
most nights in this shelter in the past 30 days. I am going to read a list of victimizations and ask you
about the clients’ experiences with them.
B1.

Did the client experience any of the following types of victimizations prior to their shelter stay?

YES

NO

DON’T
KNOW

a. Adults molested as children ..............................................

1

2

-8

b. Child sexual abuse/ sexual assault ..................................

1

2

-8

c. Rape/sexual assault other than sexual victimizations
against children.................................................................

1

2

-8

d. Stalking .............................................................................

1

2

-8

e. Child witness of violence ..................................................

1

2

-8

f.

Child physical abuse or neglect ........................................

1

2

-8

g. Elder physical abuse ........................................................

1

2

-8

h. Domestic violence/dating violence ...................................

1

2

-8

1

2

-8

j. Robbery ............................................................................
k. Human trafficking for labor ..............................................

1

2

-8

1

2

-8

l.

i.

Assault other than domestic/dating violence or
child/elder abuse...............................................................

Human trafficking for sex ..................................................

1

2

-8

m. Survivors of homicide victims ...........................................

1

2

-8

n. Witness intimidation ..........................................................

1

2

-8

o. DUI/DWI crashes ..............................................................

1

2

-8

p. Identity theft ......................................................................

1

2

-8

q. Financial fraud and exploitation other than identity theft ..

1

2

-8

r.

Motor vehicle theft ............................................................

1

2

-8

s. Other property crimes .......................................................

1

2

-8

t.

Hate crimes.......................................................................

1

2

-8

u. Child marriage or forced marriage ....................................
v. Honor related violence (IF NEEDED: physical
violence/threats/ retaliation in the name of family honor,
female genital mutilation) ..................................................

1

2

-8

1

2

-8

1

2

-8

w. Other violent crimes ..........................................................
(SPECIFY) ___________________________________
INTERVIEWER NOTE:
IF RESPONSE TO ANY OF THE ITEMS IS YES, GO TO SECTION C.

14

INTERVIEWER NOTE:
ASK IF NO VICTIMIZATIONS REPORTED IN B1.
B2.

Was the client screened for any of the following types of victimization?

YES

NO

DON’T
KNOW

a. Adults molested as children ..............................................

1

2

-8

b. Child sexual abuse/ sexual assault ..................................

1

2

-8

c. Rape/sexual assault other than sexual victimizations
against children.................................................................

1

2

-8

d. Stalking .............................................................................

1

2

-8

e. Child witness of violence ..................................................

1

2

-8

f.

Child physical abuse or neglect ........................................

1

2

-8

g. Elder physical abuse ........................................................

1

2

-8

h. Domestic violence/dating violence ...................................

1

2

-8

Assault other than domestic/dating violence or child/
elder abuse .......................................................................

1

2

-8

Robbery ............................................................................

1

2

-8

k. Human trafficking for labor ...............................................

1

2

-8

l.

i.
j.

Human trafficking for sex .................................................

1

2

-8

m. Homicide attempts ............................................................

1

2

-8

n. Witness intimidation ..........................................................

1

2

-8

o. DUI/DWI crashes ..............................................................

1

2

-8

p. Identity theft ......................................................................

1

2

-8

q. Financial fraud and exploitation other than identity theft

1

2

-8

r.

Motor vehicle theft ............................................................

1

2

-8

s. Other property crimes .......................................................

1

2

-8

t.

Hate crimes.......................................................................

1

2

-8

u. Child marriage or forced marriage ....................................
v. Honor related violence (IF NEEDED: physical
violence/threats/ retaliation in the name of family honor,
female genital mutilation) ..................................................

1

2

-8

1

2

-8

1

2

-8

w. Other violent crimes ..........................................................
(SPECIFY) ___________________________________
INTERVIEWER NOTE:
IF A THROUGH W = NO, THEN GO TO END.

15

C. Service Needs of One Client with a Disability who Experienced a Victimization

Think about the same client with a disability who spent the most nights in this shelter in the past
30 days.
C1.

Did the client need any of the following services as a result of being a victim?

a. Mental health services ...........................................
b. Crisis counseling ...................................................
c. Safety services; for example; safety planning;
witness protection; self-defense) ...........................
d. Medical services ....................................................
e. Civil legal aid; for example, protection order .........
f. Assistance for applying for benefits ......................
g. Employment services ............................................
h. Vocational training .................................................
i. Monetary assistance .............................................
j. Other......................................................................
(SPECIFY) ______________________________

C2.

YES
1
1

NO
2
2

DON’T
KNOW
-8
-8

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

-8
-8
-8
-8
-8
-8
-8
-8

Did the client receive any of the following services through in-house, vendor or contract with
other agencies, and referrals to other agencies specifically to address his/her needs as a
victim?

INTERVIEWER NOTE:
MARK NO IF THE SERVICE WAS NOT PROVIDED.

a. Mental health services ......................
b. Crisis counseling ..............................
c. Safety services; for example, safety
planning; witness protection; selfdefense)............................................
d. Medical services ...............................
e. Civil legal aid; for example,
protection orders ..............................
f. Assistance for applying for benefits .
g. Employment services .......................
h. Vocational training ............................
i. Monetary assistance ........................
j. Other.................................................
(SPECIFY) ___________________

Inhouse
1
1

YES
Vendor
(contract w/
other agency)
2
2

Referral
to other
agency
3
3

NO
4
4

DON’T
KNOW
-8
-8

1
1
1

2
2
2

3
3
3

4
4
4

-8
-8
-8

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

-8
-8
-8
-8
-8

16

C3.

Did this shelter work with any of the following types of organizations to provide services or referrals
specifically to address the client’s needs related to victimization?

a.
b.
c.
d.
e.

Law enforcement ..........................................
Hospitals, clinics or other medical providers
Legal aid organizations .................................
Victim service or advocacy organizations ....
Other organizations ......................................
(SPECIFY) _________________________

YES
1
1
1
1
1

NO
2
2
2
2
2

DON’T
KNOW
-8
-8
-8
-8
-8

Thank you very much for participating in this important study!

17

Attachment 4

<>
<>
Dear «First_Name» «Last_Name»:
We are writing to ask for your assistance in completing the Victims With Disabilities in Homeless
Shelters Pilot Survey funded by the Bureau of Justice Statistics (BJS). Persons with a disability,
particularly those who are homeless, are often not represented in research on victimization and
access to services. A primary goal of this pilot survey is to learn about the feasibility of surveying
emergency shelters to learn more about victimization and access to victim services among homeless
persons, particularly those with a disability.
BJS contracted with Westat to design and conduct this survey. The survey is in two parts:
• Part 1 focuses on gathering general information about the shelter, such as shelter
characteristics, the services provided to clients, types of victimizations and disabilities
recorded in client files, and procedures for record keeping and reporting. This section is best
completed by someone who knows about shelter record keeping, for example shelter
administrators. It takes about 20 minutes.
• Part 2 asks about experiences of one client that stayed in the shelter in the past 30 days. No
personally identifying information will be collected. Part 2 is best completed by someone
who works with individual clients, for example a program manager, and takes about 15
minutes to complete.
There are no major risks or discomforts associated with participating in this study. Your answers
will be kept private and any reports from the research will be in aggregate form. Please see
attached Frequently Asked Questions for additional information about the survey.
This survey is being conducted over the telephone. An interviewer from Westat will call you in the
near future to invite you to participate. Our records indicate you can be reached at
<< insert phone number>>. If this is incorrect, or we should be contacting someone different at
your shelter, please call Westat toll-free at 1-866-967-7457 or email Beth Rabinovich at
[email protected].
Your participation is very important to informing the development of future work on measuring
victimization and access to services among homeless persons with a disability. Although this study
is voluntary, we need and appreciate your cooperation and support to make the results
comprehensive, accurate, and timely. If you have any questions about this study please reach out to
Westat. Thank you very much for your time and participation in this important project.
Sincerely,
Beth Rabinovich
Senior Study Director

Attachment 5

Victims with Disabilities in Homeless Shelters Pilot Survey
FREQUENTLY ASKED QUESTIONS
Why are we conducting this survey?
• The purpose of the Victims with Disabilities in Homeless Shelters Pilot Survey is to survey
emergency shelters to learn about the data they collect on client experiences with criminal
victimization and access to victim services among homeless persons with a disability. This survey
will fill basic gaps in our information about emergency shelter practices in documenting
victimizations and disabilities, the types of services shelters provide, and the types of agencies
shelters work with to serve homeless persons with a disability. This work will impact future
national efforts to understand how shelters serve persons with disabilities and those who have
experienced victimization, and to identify ways in which shelters need support for serving these
populations.
What questions will be asked in the survey?
The survey is in two parts.
• Part 1 focuses on gathering general information about the shelter, such as shelter characteristics,
the service provided to clients, types of victimization and disabilities recorded in client files, and
procedures for record keeping and reporting.
•

Part 2 asks about one client that stayed in the shelter in the past 30 days, including questions
about this client’s age, gender, race/ethnicity; disability status of the client; type of victimization
experienced by the client prior to their shelter stay; and service needs of the client.

We will not ask about client names or any identifying information about clients.
Who should participate in this survey?
Emergency shelter staff, including but not limited to administrators, program managers, and case
workers, are eligible to participate in the survey. It is possible that both sections of the survey may be
completed by one person who is knowledgeable about shelter characteristics and the experiences of
clients in the shelter.
However, it is also possible that two or more individuals will complete the survey. For example, Part 2 of
the survey may be more appropriate for completion by someone who directly works with clients.
How long will it take to complete the survey?
Part 1 of the survey takes approximately 20 minutes to complete and Part 2 of the survey takes
approximately 15 minutes to complete. The entire survey takes approximately 35 minutes to complete.
Who should I contact if I have questions about this study?
If you have questions about this study, you may contact Beth Rabinovich, Principal Investigator at 1-866967-7457 or [email protected].
How can I complete the survey?
The survey will be conducted over the telephone. An interviewer from Westat will call you in the near
future to invite you to participate.

Attachment 6

INFORMED CONSENT
Purpose
Funded by the Bureau of Justice Statistics (BJS), the purpose of the Victims with Disabilities in Homeless Shelters
Pilot Survey is to survey emergency shelters to learn about the data they collect on client experiences with criminal
victimization and access to victim services among homeless persons with a disability. This survey will fill basic gaps in
our information about emergency shelter practices in documenting victimizations and disabilities, the types of services
shelters provide, and the types of agencies shelters work with to serve homeless persons with a disability.

Study Procedure
To assist with the study, we are inviting homeless shelter administrators and/or other shelter staff to participate in a
telephone survey. The survey is in two parts. Part 1 focuses on gathering general information about the shelter, such
as shelter characteristics, the service provided to clients, types of victimization and disabilities recorded in client files,
and procedures for record keeping and reporting. Part 2 asks about one client with a disability that stayed in the
shelter, including questions about this client’s age, gender, race/ethnicity; type of victimization experienced by the
client prior to their shelter stay; and service needs of the client. Completing the telephone survey takes approximately
30-35 minutes.

Voluntary Participation
Your participation in the interview as well as responding to individual interview questions is voluntary. You may decide
not to participate or to end your participation at any time.

Risks and Discomfort
There are few, if any, risks to participating in the study. However, you can skip any question you do not want to
answer.

Cost and Benefits
There will be no direct cost or benefit to you for your participation in this study. The information obtained from this
study will help inform future national efforts to understand how shelters serve persons with disabilities and those who
have experienced victimization, and to identify ways in which shelters need support for serving these populations.

Confidentiality
Any information obtained from you during this research will be kept as private as possible, to the extent of the law.
Your responses will be stored in a secure server and only the researchers will see your direct answers on the
interview. Your name or the name of the shelter will not be linked to any of your responses. We will not collection the
names of your clients or other identifying information about your clients. Data collected from this study will be
destroyed upon the completion of the project.

Contact Information
You are encouraged to ask questions about any aspect of this research by contacting the principal investigator, Beth
Rabinovich (301-315-5965; [email protected]). If you have questions about your rights and welfare as a
research participant, please call the Westat Human Subjects Office at 1-888-920-7631. Please leave a message with
your full name, the name of the research study that you are calling about (Victims with Disabilities in Homeless
Shelters Pilot Survey) and a phone number beginning with the area code. Someone will return your call as soon as
possible.
Do you have any questions?
Do you agree to participate in this interview? ___Y ___N