Service Receipt Questionnaire

Consent Language

You are invited to participate in a research project about the Affordable Housing and Supportive Services Demonstration in your community. The Administration for Children and Families (ACF) at the U.S. Department of Health and Human Services is conducting this study to understand how the program is improving services for residents of this community.

This survey asks questions about the services you have received in the past six months. Your case worker or service coordinator will also ask you some questions about your quality of life and barriers to economic mobility and family self-sufficiency. The research team would like to use your responses on this survey about service receipt and the questions about your quality of life in your residential community and barriers you face to understand how the program helps the people it serves. Your case worker or service coordinator will also use the information you provide about your quality of life and the barriers you face to improve the services they provide.

This survey should take about 15 minutes to complete. Your case worker or service coordinator can assist you in responding to the questions. Because we want to understand how the program is improving services and outcomes for people over time, we are asking for this information in winter of 2024, with a follow up at 6 months.

The research team will keep your information private. In this survey, we have requested that you provide a unique identifier that we can use to link your data from the next administration of this survey and data from your caseworker about your family’s quality of life and barriers. The unique identifier will be removed from the data once data collection is complete. The data from the study will not contain information that can be used to identify you, like your name, contact information, or social security number.

Your participation is voluntary, and you have the option to not respond to questions that you choose. Your participation or nonparticipation will not affect your services in this community.

If you have questions about the study, please contact NAME via email at EMAIL or PHONE.

By completing this survey, you consent to participate in the research project.

• I have read the above information and agree to participate in this research project.

ENTER SURVEY

PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering data on your grant program to understand the design and effectiveness of the program and to inform technical assistance needs. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact [email protected]. 

Introductions and Background

Thank you for agreeing to participate in Affordable Housing and Supportive Services Demonstration. First, please provide some background information.

What is your AHSSD Study Unique Identifier? (A staff member will provide this number for you)

How long have you lived in your current housing?

m Less than a month

m 1 to 3 months

m 4 to 6 months

m 7 to 9 months

m 10 to 12 months

m More than 12 months

m DON’T KNOW

m REFUSED

How many children under the age of 18 are in your household?

Number of children under age 18

(0-15)

m DON’T KNOW

m REFUSED

Service Receipt Information

In this section, you’ll provide information about the services you have received in the past six months.

Please tell us about assistance you have received in the past 6 months. Please include help you have received from your housing community and help you have received from other organizations or programs.

In the past 6 months, have received help with…

	Yes	No	Don’t Know	Refused
Planning your future career or educational goals?
Finding a job or a better job?
Learning about parenting or family skills?
Learning about your personal or household finances?
Enrolling your children in afterschool or recreational programs?
Finding or paying for legal support?
Obtaining food or clothing?
Finding or paying for regularly scheduled child care or care for other dependents?
Finding or paying for drop-in childcare or care for other dependents while you attend appointments, class, or take care of things?
Finding, using, or paying for transportation?
Finding or paying for housing?
Paying for basic needs like water bills, heating bills, or food?
Obtaining benefits like disability benefits, Temporary Assistance for Needy Families (TANF), Medicaid, and Unemployment Insurance?
Obtaining documents you need, such as a social security card or photo identification?
Training to learn a new job or skill?
Education to learn a new job or skill?
Getting treatment for problems related to substance use?
Getting help for problems related to your emotions, nerves, anger management, or mental health?
Getting treatment for any physical medical condition at a hospital clinic, or doctor’s office?