PHA Staff Interviews (on-site)

NATIONAL FAMILY SELF-SUFFICIENCY EVALUATION

PHA Staff Interviews

(PHA Staff Pre-Interview Tables)

Public reporting burden for this collection of information is estimated to average .5 hours per response for this Government agency staff interview. HUD may not conduct or sponsor, and a person is not required to respond to, a collection information unless that collection displays a valid OMB control number 2528-0296, expiring xx-xx-xxxx.

The information requested under this collection is protected and held private in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C.552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.

Instructions

Please write in the answers to the following three questions, complete the tables on the pages that follow, and return to MDRC at this address: _______________________

General Program & Staffing

1. How many clients are currently [or as of xx date?] enrolled in your FSS program (total number, not the number in the FSS study)?

2. How many mandatory slots do you currently have?

3. What is your annual grant funding amount (most recent)?

Staff Table: [site name]

Please update the Staff Table with all current FSS program staff. Include all staff paid using FSS funds. We are trying to understand the number of hours staff currently spend on FSS, HCV, and other responsibilities.

• Put “N/A” if staff person does not have these responsibilities.

• The # of hours that staff work on the HCV and FSS programs and other responsibilities should add up to the total number of hours currently worked per week.

	Staff Name Note with an asterisk (*) if no longer working at Housing Authority		FSS Responsibilities (not including HCV responsibilities)		HCV Responsibilities (e.g. recertifications)			Other Non-FSS Responsibilities
		Current # hours work per week	Current # HCV FSS cases (where applicable, also note # PH FSS cases)	Total # hours (or % time) spent on FSS per week	Current # of cases for whom case manager has HCV responsibilities	# of cases that are also on this case manager’s FSS caseload	Total # hours (or % time) spent on HCV per week	List other responsibilities (if applicable)	Total # of hours (or % time) spent on other per week

IR3 Service Referral and Partner Table: [site name]

Please update the Service Referral and Partner Table with all current partners including members of the FSS Program’s PCC and identify the services they provide.

Organization Name

Services provided to FSS program or FSS clients (check all that apply)

Referral Services

Non-Referral Services

Part of PCC? (Y/N)

Have formal agreement (e.g. MOU)? (Y/N)

Education & Training

Employment Prep

Postemployment Services

Benefits Assistance

Financial Services

Supportive/Social Services, (including health/wellness, childcare, and transportation)

Other

Program Guidance/Advisory

Assistance with HA Events

Other

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