VDHS Pilot Survey Instrument and Interview Protoc

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