OMB Control # 0970 – XXXX
Expiration Date: XX/XX/XXXX
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: |
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Project ID: |
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Client Name: |
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Case Manager/Worker’s Name: |
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Agency/Organization: |
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Today’s Date: |
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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].
CONTINUED ON NEXT PAGE
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): |
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☐ 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 |
CONTINUED ON NEXT PAGE
Which services have you provided directly or referred the family to another agency for services (Please Select All that Apply) [CONTINUED]: |
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☐ 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 |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Kellie Randall |
File Modified | 0000-00-00 |
File Created | 2021-06-22 |