Form 10-10162 Provider Assessment

2019 CHALENG Survey

OMB Approval Number 2900-0843

Estimated Burden Avg: 9 minutes

Expiration Date: XX/XX/XXXX

Respondent Identification

1. Which of the following best describes your reasons for taking the CHALENG survey?

• I work for the VA

• I work for another Federal Agency

• I work for a state or local government agency or a community-based homeless provider

• I am an interested member of the community

2. Did you complete a CHALENG survey last year?

Yes

No

3. In your opinion, is the agency you represent faith-based?

Yes

No

Provider’s Identification

Please only answer if you indicated that you work for the VA

1a. Which of the following best describes your organization and affiliation?

• VA Central Office

• Veterans Benefit Administration

• VA National Cemetery Administration

• VISN

• VA Medical Center

• VA Regional Office

• VA Outpatient Clinic

• Vet Center

Please only answer if you indicated that you work for a Federal agency other than the VA.

1b. Which of the following best describes your organizational affiliation?

• Department of Housing and Urban Development

• Department of Labor

• United States Interagency Council on Homelessness

• Department of Health and Human Services

• Department of Education

• Department of Defense

• Social Security Administration

• Department of Agriculture

• Department of Justice

• Department of Transportation

• Department of Interior

• Other

Please only answer if you DO NOT work for the federal government.

1c. Which of the following best describes your organizational affiliation?

• State Department of Veterans Affairs

• State or Local Health and Human Services Agency

• State or Local Mental Health Department

• State or Local Correctional Agency or Law Enforcement Organization

• Other State or Local Government Agency

• Veterans Services Organization

• Private Non-profit Community-based Organization

• Private For-profit Community-based Organization

• Other

Based on your experience serving homeless Veterans, please help us understand how well the needs of male and female Veterans are being met. Within the past 3 months (or 90 days) how well are male and female Veterans’ needs being met in the following areas:

Never Met

Always Met

N/A

Never Met

Always Met

N/A

Housing

Male

O

O

O

O

O

Female

O

O

O

O

O

Emergency/immediate Shelter

Male

O

O

O

O

O

Female

O

O

O

O

O

Transitional Living Facility and Halfway House

Male

O

O

O

O

O

Female

O

O

O

O

O

Long-term Permanent Housing

Male

O

O

O

O

O

Female

O

O

O

O

O

Registered Sex Offender Housing

Male

O

O

O

O

O

Female

O

O

O

O

O

Affordable Housing

Male

O

O

O

O

O

Female

O

O

O

O

O

Emergency Housing for Families

Male

O

O

O

O

O

Female

O

O

O

O

O

Landlord Relations and Tenancy

Male

O

O

O

O

O

Female

O

O

O

O

O

Assisted living for the elderly

Male

O

O

O

O

O

Female

O

O

O

O

O

Goods (Furniture and Housewares) for New Apartment

Never Met

Always Met

N/A

Never Met

Always Met

N/A

Treatment Services

Male

O

O

O

O

O

Female

O

O

O

O

O

Medical Services

Male

O

O

O

O

O

Female

O

O

O

O

O

Services for Emotional or Psychiatric Problems

Male

O

O

O

O

O

Female

O

O

O

O

O

TB Testing and Treatment

Male

O

O

O

O

O

Female

O

O

O

O

O

Detoxification from Substances

Male

O

O

O

O

O

Female

O

O

O

O

O

Substance Abuse Treatment

Male

O

O

O

O

O

Female

O

O

O

O

O

HIV/AIDS Testing and Treatment

Male

O

O

O

O

O

Female

O

O

O

O

O

Hepatitis C Testing and Treatment

Male

O

O

O

O

O

Female

O

O

O

O

O

Eye Care and Glasses

Male

O

O

O

O

O

Female

O

O

O

O

O

Personal Hygiene (shower, haircut, etc.)

Male

O

O

O

O

O

Female

O

O

O

O

O

Medication Management

Male

O

O

O

O

O

Female

O

O

O

O

O

Elder Healthcare and Resources

Male

O

O

O

O

O

Female

O

O

O

O

O

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

Male

O

O

O

O

O

Female

O

O

O

O

O

Treatment for Dual Diagnosis

Male

O

O

O

O

O

Female

O

O

O

O

O

Case Management

Male

O

O

O

O

O

Female

O

O

O

O

O

Parent Education

Male

O

O

O

O

O

Female

O

O

O

O

O

Military Sexual Trauma

Male

O

O

O

O

O

Female

O

O

O

O

O

Dental Care

Never Met

Always Met

N/A

O

O

O

O

O

Women Only: Women’s Specific Mental Health Providers

O

O

O

O

O

Women Only: OB-GYN Services

O

O

O

O

O

Women Only: Breastfeeding Information and Supplies

O

O

O

O

O

Women Only: Women Specific Health Care Provider Availability

O

O

O

O

O

Women Only: Domestic Violence Support Services

Never Met

Always Met

N/A

Never Met

Always Met

N/A

Income/Benefits Services

Male

O

O

O

O

O

Female

O

O

O

O

O

1. VA Disability/Pension

Male

O

O

O

O

O

Female

O

O

O

O

O

2. Welfare Payments

Male

O

O

O

O

O

Female

O

O

O

O

O

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

Male

O

O

O

O

O

Female

O

O

O

O

O

4. Money Managing

Male

O

O

O

O

O

Female

O

O

O

O

O

5. Food

Male

O

O

O

O

O

Female

O

O

O

O

O

6. Clothing

Male

O

O

O

O

O

Female

O

O

O

O

O

7. Credit Counseling

Male

O

O

O

O

O

Female

O

O

O

O

O

8. Family Reconciliation Assistance

Male

O

O

O

O

O

Female

O

O

O

O

O

9. Social Networking

Male

O

O

O

O

O

Female

O

O

O

O

O

10. Move-In Assistance

Male

O

O

O

O

O

Female

O

O

O

O

O

11. Utility Assistance

Male

O

O

O

O

O

Female

O

O

O

O

O

12. Discharge Upgrade

Male

O

O

O

O

O

Female

O

O

O

O

O

13. Family and Marital Counseling

Male

O

O

O

O

O

Female

O

O

O

O

O

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

Male

O

O

O

O

O

Female

O

O

O

O

O

15. Child Care

Male

O

O

O

O

O

Female

O

O

O

O

O

16. Basic Communication (working cell phone or phone)

Male

O

O

O

O

O

Female

O

O

O

O

O

17. Basic Contact Information (reliable mailing address)

Male

O

O

O

O

O

Female

O

O

O

O

O

18. Financial Assistance to Prevent Eviction or Foreclosure

Never Met

Always Met

N/A

Never Met

Always Met

N/A

Legal Assistance

Male

O

O

O

O

O

Female

O

O

O

O

O

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

Male

O

O

O

O

O

Female

O

O

O

O

O

2. Financial Guardianship

Male

O

O

O

O

O

Female

O

O

O

O

O

3. Help Getting Identification and Legal Documents

Male

O

O

O

O

O

Female

O

O

O

O

O

4. Re-Entry Services for Incarcerated Veterans

Male

O

O

O

O

O

Female

O

O

O

O

O

5. Legal Assistance for Child Support Issues

Male

O

O

O

O

O

Female

O

O

O

O

O

6. Legal Assistance for Outstanding Warrants and Fines

Male

O

O

O

O

O

Female

O

O

O

O

O

7. Legal Assistance to Prevent Eviction and Foreclosure

Male

O

O

O

O

O

Female

O

O

O

O

O

8. Legal Assistance to Expunge a Criminal Record

Male

O

O

O

O

O

Female

O

O

O

O

O

9. Legal Assistance for Credit Issues/Debt Collection

Male

O

O

O

O

O

Female

O

O

O

O

O

10. Legal Assistance for Court Fees/Court Fines

Male

O

O

O

O

O

Female

O

O

O

O

O

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

Male

O

O

O

O

O

Female

O

O

O

O

O

12. Domestic Violence/Protection Orders

Male

O

O

O

O

O

Female

O

O

O

O

O

13. Tax Issues

Male

O

O

O

O

O

Female

O

O

O

O

O

14. Discharge Upgrade Appeals

Male

O

O

O

O

O

Female

O

O

O

O

O

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

Never Met

Always Met

N/A

Never Met

Always Met

N/A

Education/Job Services

Male

O

O

O

O

O

Female

O

O

O

O

O

1. Education

Male

O

O

O

O

O

Female

O

O

O

O

O

2. Job Training

Male

O

O

O

O

O

Female

O

O

O

O

O

3. Finding a Job or Getting Employment

Male

O

O

O

O

O

Female

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)

Male

O

O

O

O

O

Female

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

Always Met

N/A

Never Met

Always Met

N/A

Community Partnerships

Male

O

O

O

O

O

Female

O

O

O

O

O

1. Drop-in Center and Day Program

Male

O

O

O

O

O

Female

O

O

O

O

O

2. Spiritual

Male

O

O

O

O

O

Female

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)