Form for community agency points of contact to verify agency information (monthly)

Agency Information Form

Completed Monthly

DVHF Demonstration Evaluation

Directions to Project Coordinator: On a monthly basis, for the first 19 months after data collection begins, please ask each agency POC to help complete this brief form.

Question:	Response:
1. Agency ID	Unique ID# pre-determined
2. Date of completion	Date
3. Number of direct service staff available today to provide DVHF services to survivors:	Actual number
4. Average caseload of direct service providers who provide DVHF (even if they also provide other services):	Actual number
5. Number of permanent housing vouchers available to this agency to give out in the prior 30 days:	Actual number
6. How many days in the prior 30 days did your agency have an opening in your shelter program?	Actual number
7. How many days in the prior month did your agency have an opening in your transitional housing program?	Actual number 0 - 31
8. How much money does your agency have available today that can be used for flexible funding?	Actual number rounded to dollar