Form 10-10161 Veteran Assessment

Veterans Health Administration Homeless Programs - Project Chaleng (Community Homelessness Assessment, Local Education and Networking Groups) for Veterans

proposed_2019 CHALENG Veteran Survey_Word

Veteran Survey

OMB: 2900-0843

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2019 CHALENG Survey

OMB Approval Number 2900-0843

Estimated Burden Avg: 6 minutes

Expiration Date: XX/XX/XXXX


Identification:

  1. In which branch of the armed services did you serve?

  • Army

  • Navy

  • Marine Corps

  • Air Force

  • Coast Guard

  • National Guard/Reserve


  1. Where are you living now?

  • Literally Homeless (on streets, in shelter, in car)

  • Emergency Housing

  • Transitional Housing (Grant and Per Diem housing, VA Domiciliary, or community contract housing

  • Permanent subsidized housing (including HUD-VASH and Section 8)

  • Unsubsidized housing (private apartment/house/condominium)


Please only answer these questions if you answered question #2 with “Literally Homeless.” All other Veterans should skip questions 2(a) and 2(b).


2(a) Which of the following options best describes how long you have been homeless?

  • 0-3 months

  • 4-6 months

  • 7-12 months

  • 13-24 months

  • More than 24 months


2(b) Have you had four or more episodes of homelessness in the past three years?

  • Yes

  • No


Please only answer this question if you answered question #2 with “Unsubsidized housing.” All other Veterans should skip question 2(c).


2(c) Do you own or rent?

  • Own

  • Rent


  1. What is your gender?

  • Male

  • Female



  1. What is your age?

  • Less than 25

  • 25-34

  • 35-44

  • 45-60

  • 61+


5a. What race do you most strongly identify with?

  • American Indian or Alaska Native

  • Asian

  • Black or African American

  • Native Hawaiian or Other Pacific Islander

  • White

  • Don’t Know


5b. What ethnicity do you most strongly identify with?

  • Non-Hispanic/Non-Latino

  • Hispanic/Latino

  • Don’t Know


  1. How many dependents under the age of 18 are residing with you?

  • 0

  • 1

  • 2

  • 3

  • 4 or more


  1. Are you currently enrolled in the VA?

  • Yes

  • No

  • Unsure


  1. Is your housing in any way at risk (do you have trouble making mortgage payments, or are your housing plans uncertain)?

  • Yes

  • No


  1. Do you live in a rural or frontier community?

  • Yes

  • No


Please tell us in your own words: What is the most important resource/service that could help end your homelessness now, or if you are formerly homeless, what is the most important resource that will prevent you from being homeless in the future?




Based on your experience as a Veteran experiencing homelessness or former homelessness, please help us understand how well your needs are being met. Within the past 3 months (or 90 days) how well are your needs being met in the following:


Never

Met

Shape1


Always

Met

N/A

Housing

O

O

O

O

O

  1. Emergency/immediate Shelter

O

O

O

O

O

  1. Transitional Living Facility and Halfway House

O

O

O

O

O

  1. Long-term Permanent Housing

O

O

O

O

O

  1. Registered Sex Offender Housing

O

O

O

O

O

  1. Affordable Housing

O

O

O

O

O

  1. Emergency Housing for Families

O

O

O

O

O

  1. Landlord Relations and Tenancy

O

O

O

O

O

  1. Assisted living for the elderly

O

O

O

O

O

  1. Goods (Furniture and Housewares) for New Apartment

Never

Met

Shape2


Always

Met

N/A

Treatment Services

O

O

O

O

O

  1. Medical Services

O

O

O

O

O

  1. Services for Emotional or Psychiatric Problems

O

O

O

O

O

  1. TB Testing and Treatment

O

O

O

O

O

  1. Detoxification from Substances

O

O

O

O

O

  1. Substance Abuse Treatment

O

O

O

O

O

  1. HIV/AIDS Testing and Treatment

O

O

O

O

O

  1. Hepatitis C Testing and Treatment

O

O

O

O

O

  1. Eye Care and Glasses

O

O

O

O

O

  1. Personal Hygiene (shower, haircut, etc.)

O

O

O

O

O

  1. Medication Management

O

O

O

O

O

  1. Elder Healthcare and Resources

O

O

O

O

O

  1. Health and Wellness (preventing illness and prolonging life through diet, exercise and self care)

O

O

O

O

O

  1. Treatment for Dual Diagnosis

O

O

O

O

O

  1. Case Management

O

O

O

O

O

  1. Parent Education

O

O

O

O

O

  1. Military Sexual Trauma






  1. Dental Care:






How would you describe the health of your teeth and gums?






O Excellent






O Very good






O Good






O Fair






O Poor

Never

Met

Shape3


Always

Met

N/A


O

O

O

O

O

  1. Women Only: Women’s Specific Mental Health Providers

O

O

O

O

O

  1. Women Only: OB-GYN Services

O

O

O

O

O

  1. Women Only: Breastfeeding Information and Supplies

O

O

O

O

O

  1. Women Only: Women Specific Health Care Provider Availability

O

O

O

O

O

  1. Women Only: Domestic Violence Support Services


Never

Met

Shape4


Always

Met

N/A

Income/Benefits Services

O

O

O

O

O

1. VA Disability/Pension

O

O

O

O

O

2. Welfare Payments

O

O

O

O

O

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

O

O

O

O

O

4. Money Managing

O

O

O

O

O

5. Food

O

O

O

O

O

6. Clothing

O

O

O

O

O

7. Credit Counseling

O

O

O

O

O

8. Family Reconciliation Assistance

O

O

O

O

O

9. Social Networking

O

O

O

O

O

10. Move-In Assistance

O

O

O

O

O

11. Utility Assistance

O

O

O

O

O

12. Discharge Upgrade

O

O

O

O

O

13. Family and Marital Counseling

O

O

O

O

O

14. Transportation (includes transportation for disabled Veterans and Veterans with dependent children)

O

O

O

O

O

15. Child Care

O

O

O

O

O

16. Basic Communication (working cell phone or phone)

O

O

O

O

O

17. Basic Contact Information (reliable mailing address)

O

O

O

O

O

18. Financial Assistance to Prevent Eviction or Foreclosure

Never

Met

Shape5


Always

Met

N/A

Legal Assistance

O

O

O

O

O

1. Legal Assistance to Help Restore a Driver’s License

O

O

O

O

O

2. Financial Guardianship

O

O

O

O

O

3. Help Getting Identification and Legal Documents

O

O

O

O

O

4. Re-Entry Services for Incarcerated Veterans

O

O

O

O

O

5. Legal Assistance for Child Support Issues

O

O

O

O

O

6. Legal Assistance for Outstanding Warrants and Fines

O

O

O

O

O

7. Legal Assistance to Prevent Eviction and Foreclosure

O

O

O

O

O

8. Legal Assistance to Expunge a Criminal Record

O

O

O

O

O

9. Legal Assistance for Credit Issues/Debt Collection

O

O

O

O

O

10. Legal Assistance for Court Fees/Court Fines

O

O

O

O

O

11. ADA issues with rental housing (i.e. ramps for wheelchair access, accommodation of service animals)

O

O

O

O

O

12. Domestic Violence/Protection Orders

O

O

O

O

O

13. Tax Issues

O

O

O

O

O

14. Discharge Upgrade Appeals

O

O

O

O

O

15. Family Law (i.e. divorce, child custody)

Never

Met

Shape6


Always

Met

N/A

Education/Job Services

O

O

O

O

O

1. Education

O

O

O

O

O

2. Job Training

O

O

O

O

O

3. Finding a Job or Getting Employment

O

O

O

O

O

4. Life Skills Training (learning to cope with stresses and challenges of daily life, particularly skills in communication, literacy, decision-making, occupational requirements, problem-solving, time management, and planning)

O

O

O

O

O

5. Vocational Rehabilitation (a process that enables people with functional, psychological, developmental, cognitive, or emotional impairments or health conditions to overcome barriers to accessing, maintaining, or returning to employment)


Never

Met

Shape7


Always

Met

N/A

Community Partnerships

O

O

O

O

O

1. Drop-in Center and Day Program

O

O

O

O

O

2. Spiritual

O

O

O

O

O

3. Prevention (services to stop Veterans and their families from becoming homeless, including ways to avert housing loss for households facing eviction and housing resources when discharged from hospitals, jails, and prisons)

Not Accessible



Very Accessible

N/A


O

O

O

O

O

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

Not Able



Mostly Able

N/A


O

O

O

O

O

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

Not Aware



Mostly Aware

N/A


O

O

O

O

O

6. How aware of Veterans’ needs and resources are Community Homeless Agencies?





Thank you for your participation in the CHALENG survey! If you would like more information or if you have any concerns, please contact the Call Center for Homeless Veterans:

http://www.va.gov/homeless/nationalcallcenter.asp | 1-877-4AID VET (1-877-424-3838)

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