Appendix G. Lost-to-Project Form_OAHM_Final

Approved OMB Control No: [to be inserted] Final

Expiration Date [to be inserted] 1/5/2022

Appendix G

Lost-to-Project Form

Older Adults Home Modification Program

Lost-to-Project Form¹

Study ID: (auto-filled by REDCap)
Site ID	Client ID

OMB Control No. 2528-XXXX, expiration date XX/XX/2024. This form is designed to provide HUD with information about how effective its Older Adults Home Modification Grant Program is. Your participation in the Evaluation as a grantee is mandatory as a condition of the grant. The Public reporting burden for your collection of information is estimated to be 5 minutes per response. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.

Home (choose only one):

□ Has not been enrolled in the OAHM Program and is ineligible for the program Go to Section A (REDCap: Do not allow Section B to be completed).

□ Needs to be de-enrolled after being enrolled in the OAHM Program Go to Section B (REDCap: Do not allow Section A to be completed.)

Section A. Home Ineligibility Documentation

Fill out this section if the home was found to be ineligible before enrollment.

Date Client was found ineligible (mm/dd/yyyy)	Section A Completed By:
	Name	Organization	Job Title
			(dropdown menu: administrative staff, program staff, project manager, program manager,  other [Specify])

Home was found ineligible for OAHM Program due to: (REDCap: Allow grantee to check all that apply)

□ Homeowner(s) was/were less than 62 years old

□ Applicant did not own the home they wanted to enroll in the program

□ Applicant did not live in the home they wanted to enroll in the program

□ Annual household income was above 80% AMI

□ Home structure was not a good fit for the OAHM Program Why not?___________________

□ Work estimate exceeded $5,000, and HUD did not approve

□ Other reason. Specify:_________________________________________

Section B. De-Enrollment Documentation

Fill out this section if the home was fully enrolled in the OAHM grant program but lost to follow-up before the program period ended.

Date client was de-enrolled (mm/dd/yyyy)	Section B Completed By:
	Name	Organization	Job Title
			(dropdown menu: administrative staff, program staff, project manager, program manager, other [Specify])

Reason the home/client was lost to follow-up: Check one box.

□ Client no longer wishes to participate in the OAHM Program (or by association, the Evaluation)

□ Client declined to sign the Informed Consent.

□ Client signed the Informed Consent and is still in the OAHM Program, but no longer wishes to participate in the Evaluation. Check this box if the person declines further participation in the Evaluation (e.g., 6- to 9-month follow-up visit) but stays in the OAHM Program.

□ Unable to contact client after repeated attempts

□ Client became ill or was injured in a manner which prevented further participation

□ Client died. Approximate date of death, if known: ___________

□ Client moved out of home (check only one below): Approximate date of move, if known:_______

□ Relocated to assisted living or other facility offering medical services

□ Relocated to a relative’s home

□ Relocated to a location other than those listed above. (Specify)__________________

List reason for relocation, if known:______________________________________________

□ Other reason for de-enrollment not listed above. (Specify):__________________________________________________________________

1 Code for this document: Black font=Question asked of the grantee; Blue italics = Instruction for the grantee; yellow highlighted italics: Instruction for REDCap programmer.