VA Form 10-10072b SSVF Quarterly Grantee Performance Report

OMB Control Number: 2900-0757

Estimated Burden: 2.25 hours

Expiration Date: XX/XX/XXXX

U.S. Department of Veterans Affairs

Supportive Services for Veteran Families (SSVF) Program

Quarterly Grantee Performance Certification

The Paperwork Reduction Act of 1995: This information is collected in accordance with Section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of information is estimated to average 2.25 hours per response, including the time to review instructions, search existing data sources, gather and maintain data needed, and complete and review the collection of information. Respondents should be aware that we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. This collection of information is intended to assist the SSVF Program Office in monitoring grantee performance and compliance with the requirements for supportive services grants under the SSVF Program. Response to this quarterly grantee performance certification is voluntary, and failure to participate will have no adverse effect on benefits to which you might otherwise be entitled.

Privacy Act Statement: VA is asking you to provide the information requested in this form under the authority of 38 U.S.C. section 2044 in order for VA to monitor your performance pursuant to a supportive services grant under the SSVF Program. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information for: civil or criminal law enforcement; congressional communications; the collection of money owed to the United States; litigation in which the United States is a party or has interest; the administration of VA grant programs, including verification of your eligibility to participate; and personnel administration. You do not have to provide the requested information to VA; but if you do not, VA may be unable to continue your participation in this program. This information also may be used for other purposes, as authorized or required by law.

Instructions: Please complete the following form and submit via the SSVF Grants Management system.

Grantee Name:

SSVF Grant Amount:

Grant Award Number:

Name and Title of Contact Completing Form: ________________________________________

Contact Email: ___________________________________________________________________

FINAL RULE

1. I certify that this SSVF program is in compliance with the Final Rule (38 CFR part 62).

Yes/No

2. I certify that this program is operating in compliance with my signed grant agreement.

Yes/No

DATA QUALITY

3. I certify that our program is participating in the SSVF Participant Satisfaction survey to maintain compliance with our grant agreement.

Yes/No

4. I certify that our program reviews the quarterly SSVF Participant summary reports.

Yes/No

5. I certify that our program has successfully uploaded HMIS data into the VA repository every month this quarter and this data accurately represents our program performance.

Yes/No5a. If the answer to the previous question was no, please outline your plan to improve upload quality including timelines/dates.

6. I certify that our program has a data quality policy and procedures in place to ensure accurate and complete data entries which includes review of the monthly quality reports provided by the VA repository.

Yes/No

7. I certify that our program is on target to meet annual goal of household served as stated in our grant agreement.

Yes/No

7a. If the answer to the previous question was no, please outline your plan to meet goal, including timelines/dates

8. I certify that Residential Move-In Dates are entered as soon as Rapid Re-Housing clients move in to a permanent residence.

Yes/No

9. I certify our program is providing Health Care Navigation services.

Yes/No

10. I certify that our program is offering Rapid Resolution services

Yes/No

11. I certify that our program is offering Shallow Subsidy services

Yes/No

12. I certify that our program is providing Legal services

Yes/No

12a, If No, please explain

13. I certify the supportive services listed below are being provided, as indicated, per SSVF Regulation 38 CFR 62.33.

Yes/No

SUPPORTIVE SERVICES

Type of Benefit/Service (See 38 CFR 62.33 for definitions of these services)*	Grantee/program provided benefit directly (Yes/No)	Grantee/program assisted participants in obtaining benefit through referrals to other organizations (Yes/No)
Health care services	 Yes  No	 Yes  No
Daily living services	 Yes  No	 Yes  No
Personal financial planning services	 Yes  No	 Yes  No
Transportation services	 Yes  No	 Yes  No
Income support services	 Yes  No	 Yes  No
Fiduciary and representative payee services	 Yes  No	 Yes  No
Legal services	 Yes  No 	 Yes  No
Child care	 Yes  No	 Yes  No
Housing counseling, housing search	 Yes  No	 Yes  No
Other: __________________	 Yes  No 	 Yes  No
Other: __________________	 Yes  No	 Yes  No
Other: __________________	 Yes  No	 Yes  No

TRAININGS AND WEBINARS

14. I certify SSVF Program staff, including fiscal staff involved with SSVF Grant administration, have completed the annual SSVF webinar training, related to auditing, fraud prevention, financial reporting and grant compliance, within the last 365 days.

Yes/No

15 . I certify SSVF Program staff have completed the annual VA Suicide Prevention Training (S.A.V.E. Training); either in person or via webinar training in the last 365 days.

Yes/No

16. I certify that SSVF Program staff (new and existing) review all trainings/webinars/office hours provided by the SSVF Program Office.

Yes/No

17. I certify that all new SSVF Program staff have completed online trainings as indicated in the New Employee Orientation Guide (Case Manager, Health Care Navigator, Program Manager, Fiscal, etc.)

Yes/No

EXPENDITURES AND DRAWDOWNS

18. I certify that payment requests from HHS Payment Management System reflect actual spending of designated SSVF funding.

Yes/No

19. I certify that all expenditures are for line item costs approved on the last approved SSVF Budget.

Yes/No

20. I certify that I have received approval from the SSVF Program Office for any modifications made to my approved SSVF budget, including but not limited to adding new positions, adding or removing subcontractors, and cost allocations over 10% of the overall approved budget.

Yes/No

21. I certify that all spending is in compliance with all OMB regulations.

Yes/No

22. I certify understanding, grant expenditures that are not used in a manner consistent with SSVF Program goals and regulations may be recouped by the SSVF Program Office to be repurposed to provide supportive services in areas with higher needs.

Yes/No

23. I certify that actual expenditures, as of the end of this quarter, are within spending limitations. Projected spending rates per quarter: Q1 = 15 to 35%, Q2 = 40 to 60%, Q3 = 65 to 80%.

Yes/No

Additional feedback for SSVF Compliance Office:

CERTIFICATION AND SUBMISSION

I certify that I am authorized to submit this response on behalf of this SSVF program. Please note: Documentation supporting all certifications must be maintained by the grantee and made available for monitoring visits and audits.

5

10-10072b

VA Form

Nov 2021