Instrument 12: Housing Status Form

OMB Control # 0970 – 0514

Expiration Date: XX/XX/XXXX

Instrument 12: Housing Status Form

Housing Status Form

This information is being collected to assess the housing status of families being served by [CHILD WELFARE OR REFERRING AGENCY] to help identify families eligible for the Family Unification Program (FUP). For families referred to FUP, the information collected on this form can be transferred directly to the FUP Referral Form. This information is also being collected to inform the evaluation of the Family Unification Program 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 [CHILD WELFARE OR REFERRING AGENCY]. All the information you provide will be kept private to the extent permitted by law.

This form collects housing information aligned with definitions of homelessness and housing instability created by the US Department of Housing and Urban Development’s (HUD). Agencies may reformat the form and add (but not remove) items as needed,

Status Assessment Date:__________________________________

Child Welfare ID:_______________________________

Location of current residence (e.g. zip code, to be adapted to conform with each site’s housing authority requirements): ___________________________________

Worker name:________________________ Supervisor name:_______________________

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 two 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 #: 0970-0514, Exp: 09/31/2021. 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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Child Welfare Involvement

Client has an open DCF child welfare case: Y ☐ N ☐

Case type (current): ☐ Reunification ☐Family Preservation

Current Living Situations

Where is the family currently living?

☐ Private house/apartment of own

☐ With friends or relatives

☐ In place not designed for sleeping accommodation for human beings (e.g. car, park, abandoned building, bus or train station, airport, camping ground)

☐ Emergency shelter (SKIP TO PAST LIVING SITUATION SECTION)

☐ Transitional housing (SKIP TO PAST LIVING SITUATION SECTION)

☐ Hotel or motel paid for by charity or government agency (SKIP TO PAST LIVING SITUATION SECTION)

☐ Residential substance abuse treatment* (SKIP TO PAST LIVING SITUATION SECTION)

☐ Hospital (includes psychiatric hospitals) * (SKIP TO PAST LIVING SITUATION SECTION)

☐ Jail/incarcerated* (SKIP TO PAST LIVING SITUATION SECTION)

☐ Other, specify*:

*If client is in an institution (Residential SA treatment, psychiatric hospital, jail/incarcerated):

Will the client have access to stable housing upon exit? Y ☐ N ☐

What is their discharge date:____/____/______ (MMDDYYYY)

Was the client homeless (in place not designed for sleeping accommodation/emergency shelter) prior to entering the institution)? ____________

Do any of the following describe the families current living situation? For each of the following, check Yes (Y), No (N), or Unknown (U)

Family Is homeless

Family will lose their primary nighttime residence within 14 days Y ☐ N ☐ U ☐

IF YES: No subsequent residence has been identified Y ☐ N ☐ U ☐

IF YES: family lacks the resources/support, to obtain other

permanent housing. Y ☐ N ☐ U ☐

Family is fleeing or is attempting to flee domestic violence Y ☐ N ☐ U ☐

Living in dilapidated housing

The unit does not provide safe and adequate shelter and in its present

condition endangers the health, safety or well-being of the family. Y ☐ N ☐ U ☐

The unit has defects which repair or rebuilding. Y ☐ N ☐ U ☐

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Do any of the following describe the families current living situation? For each of the following, check Yes (Y), No (N), or Unknown (U) [CONTINUED]

Family is living in substandard housing

Housing unit does not have :

Operable indoor plumbing. Y ☐ N ☐ U ☐

Usable flush toilet inside the unit for the exclusive use of a family. Y ☐ N ☐ U ☐

Usable bathtub or shower inside the unit for the exclusive use of a family. Y ☐ N ☐ U ☐

Electricity, or has inadequate or unsafe electrical service. Y ☐ N ☐ U ☐

A safe or adequate source of heat. Y ☐ N ☐ U ☐

A kitchen. Y ☐ N ☐ U ☐

Housing unit has been declared unfit for habitation by an agency or

government Y ☐ N ☐ U ☐

Family is living in an overcrowded unit (3 or more people per bedroom or household head sharing a room with an adult that is not a significant other)

The family is living with its child(ren) in a unit that is overcrowded and this

overcrowded may result in the imminent placement of its child(ren) in

out-of-home care. Y ☐ N ☐ U ☐ Child(ren) not with family and if the family is re-united, the caregivers’

housing unit would be overcrowded Y ☐ N ☐ U ☐

Family is living with a household member that could result in

placement of child or delay of discharge from placement. Y ☐ N ☐ U ☐

FUP Referral

If you choose to refer this family to the Family Unification Program (FUP), you can copy the items on this form directly to the FUP Referral form or attach it to the FUP Referral form.

Family is living in a unit not accessible to disabled child(ren) Y ☐ N ☐ U ☐

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