Appendix S: Ongoing Services Questionnaire

OMB Control # 0970 – XXXX

Expiration Date: XX/XX/XXXX

Appendix S: Ongoing Services Questionnaire

On-Going Services Questionnaire

This information is being collected to inform the evaluation of the Family Unification Program (FUP) being conducted by a research team at the Urban Institute, Chapin Hall at the University of Chicago and Child Trends. This information will be used to inform the US Department of Health and Human Services Administration for Children and Families (HHS ACF) and the US Department of Housing and Urban Development to improve the administration of the FUP program. This form should be completed by staff at [RELEVANT AGENCY OR AGENCIES]. All the information you provide will be kept private to the extent permitted by law

This questionnaire will ask about the services that you have provided to the family after they have signed a lease. Please fill this form out for each family referred to the FUP program that you provided services to after they leased up into housing. Please fill out this form when the family associated with the Child Welfare ID had a lease for 6 months or when if they have signed a lease and exited the program.

Family’s Child Welfare ID:
Project ID:
Client Name:
Case Manager/Worker’s Name:
Agency/Organization:
Today’s Date:

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to evaluate the effectiveness of the Family Unification Program. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Michael Pergamit at [email protected].

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Service provision

Have you been providing case management services to the family since the family leased up?  Yes No

Are you currently providing any case management services to the family?

 Yes  No, specify when stopped: ___________

How much longer do you anticipate providing services to the family? ______________ months

Has any other agency/organization been providing case management services to the family since the family leased up?

 Yes, please specify the agency/organization: ____________________________________ No

How many times per month did you meet with the family after the family leased up?

_________________ per month

Is this more often than you typically meet with a client?  More  Less  Same

If you are a public child welfare agency case worker, did you keep the family’s case open longer than you would have normally to provide these services?  Yes No

If yes, how much longer? __________ months

If no, did you provide services after the case had closed?  Yes No

Have you conducted a needs assessment with the family?  Yes No

If yes, what needs were assessed:  Housing needs  Behavioral/Physical Health needs

 Employment/Education needs Child care Other, specify: ______________________________________________

Which services have you provided directly or referred the family to another agency for services (Please Select All that Apply):
☐ Provided ☐ Referred	Adult education/employment	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Domestic violence services	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Child substance abuse treatment	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Adult substance abuse treatment	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Family or adult counseling	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Parenting education	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Self-Sufficiency	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Access to Benefits (SSI, WIC,SNAP)	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Child care	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Legal aid	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Health services	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Child counseling	If referred, received: ☐ Yes ☐ No ☐ Unknown

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Which services have you provided directly or referred the family to another agency for services (Please Select All that Apply) [CONTINUED]:
☐ Provided ☐ Referred	Budgeting or money management	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Landlord-tenant mediation	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Subsequent-move counseling	If referred, received: ☐ Yes ☐ No ☐ Unknown
☐ Provided ☐ Referred	Other, please specify:	If referred, received: ☐ Yes ☐ No ☐ Unknown
Thinking about the services that were marked as either provided or referred, are these services your non-FUP clients typically would receive?  Yes No

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