Semi Annual Report MANDATORY
Office of Community Services Affordable Housing and Supportive Services Demonstration Data Collection
Instrument 5 - Semi-Annual Report MANDATORY.xlsx
Semi Annual Report MANDATORY
OMB: 0970-0628
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0628 can be found here:
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Direct Services
Referrals
Housing Community
Partners
Characteristics
Overview
PRA StatementDirect Services
Referrals
Housing Community
Partners
Characteristics
Sheet 1: PRA Statement
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Sheet 2: Direct Services
| Direct Services | ||||
| Provide service delivery data on the services funded directly by AHSSD this reporting period. These services may be provided directly by the CAA or by partners receiving funding for the provision of AHSSD services. | ||||
| One-on-One Intensive Services | ||||
| Please report the number of individuals who receive one-on-one intensive services, which are individualized, ongoing services to address the distinct needs of the indiviual or family. | ||||
| Service Type | # of unduplicated individuals receiving service from AHSSD | # of sessions held | Description of service activities for service type (i.e., length of typical session, remote or in-person, etc.) | Please describe the primary focus of the services (e.g., general case management to address self-sufficiency needs, family coaching, financial counseling, housing counseling, career counseling, education coaching) |
| General case management or service coordination for individuals | ||||
| Health and Support Services | ||||
| Service Type | # of unduplicated individuals receiving service from AHSSD | # of appointments, treatments, sessions, or enrollments provided | Description of types of service activities for service type (i.e., preventative or specialist, in-person or remote, group event or one-on-one) | |
| Physical health services | ||||
| Mental health services | ||||
| Substance abuse services | ||||
| Disability services | ||||
| Older adult care services | ||||
| Health insurance enrollment | ||||
| Other (please specify) | ||||
| Training Services | ||||
| Service Type | # of unduplicated individuals receiving service from AHSSD | # of trainings held | Description of service activities for service type (i.e., length of typical training, remote or in-person, etc.) | |
| Financial literacy training | ||||
| Health and wellness education | ||||
| Parenting and family skills | ||||
| Other training (please specify) | ||||
| Resources for Individuals | ||||
| Resource Type | # of unduplicated individuals receiving service from AHSSD grant recipient | # of resources distributed this reporting period | Description of resources provided | |
| Transportation assistance | ||||
| Funds to support basic needs | ||||
| Funds to reduce barriers to self-sufficiency | ||||
| Other (please specify) | ||||
| Resources for the Community | ||||
| Resource Type | Estimated # of individuals using the resources | Estimated # of times resource used by residents | Description of resources provided and how it benefits residents | |
| Community garden | ||||
| Computers or other technology | ||||
| Vehicles | ||||
| Other resources available to the community (please specify) | ||||
| Occasional or Short-Term Services | ||||
| Service Type | # of unduplicated individuals receiving service from AHSSD | # of times service provided to individuals | Description of service activities for service type (i.e., days and hours provided) | |
| Drop-in childcare | ||||
| Other occasional or short-term services (please specify) | ||||
| Community-Building Services | ||||
| Service Type | # of unduplicated individuals receiving service from AHSSD | # of events, meetings, or elections | Description of service activities for service type | |
| Community events to build relationships between neighbors | ||||
| Community board/tenant council participation | ||||
| Elections for community board/tenant council | ||||
| Other (please specify) | ||||
Sheet 3: Referrals
| Referrals to Wraparound Services | ||||
| Use this form to report the number of referrals to services that are not directly funded by the AHSSD grant this reporting period. These services may be provided by an external organization or a different department of your organization that is not funded by the AHSSD grant. | ||||
| For each service, enter the number of unduplicated individuals who were referred to the service type, the number of individuals for whom your organization tracked access to that service type, and the number of individuals for whom your organization has confirmed access to that service type. If you did not track the number of individuals who were able to access the service, you should enter "0" for the second two columns. | ||||
| Summary of Referrals by Service Type | ||||
| Referral to service type | # of unduplicated individuals referred | # of unduplicated individuals tracked for accesssing service | # of unduplicated individuals accessing the service | Notes |
| Food assistance | ||||
| Utilities assistance | ||||
| Housing assistance | ||||
| Child care services | ||||
| Youth supports and programs, including afterschool and other youth programs | ||||
| Older adult care services | ||||
| Services for individuals with disabilities | ||||
| Employment and training services | ||||
| Educational services for adults | ||||
| Clothes, uniforms, tools | ||||
| Domestic violence support and assistance | ||||
| Family relationships services | ||||
| Financial counseling | ||||
| VITA and other tax advice or assistance | ||||
| Legal advice, record expungement | ||||
| Immigration assistance | ||||
| Physical health treatment | ||||
| Mental health treatment | ||||
| Substance abuse treatment | ||||
| Stable housing support services | ||||
| Stress reduction services | ||||
| Transportation services | ||||
| Tuition assistance | ||||
| Other (please specify) | Please specify service type for other referrals: | |||
| Total Number of Individuals Receiving at Least One Referral | ||||
| # of unduplicated individuals referred for any service | # of unduplicated individuals tracked for accesssing any service | # of unduplicated individuals accessing any service | Notes | |
| Received at least one referral | ||||
Sheet 4: Housing Community
| Housing Community Indicators | ||||||
| Please provide the requested information for the housing communities supported by the AHSSD program for the quarters covered by this reporting period. | ||||||
| Indicator | Q4 2023 | Q1 2024 | Q2 2024 | Q3 2024 | Q4 2024 | Q1 2025 |
| 10/1/23 - 12/31/23 | 1/1/2024 - 3/31/2024 | 4/1/2024 - 6/30/2024 | 7/1/2024 - 9/30/2024 | 10/1/2024 - 12/31/2024 | 1/1/2025 - 3/31/2025 | |
| Total # of units occupied for some portion of time this quarter | ||||||
| Total unduplicated # of individuals residing in housing community for some portion of time this quarter | ||||||
| # of units current on paying rent for all months this quarter (if applicable) | ||||||
| # of households moving out of community this quarter | ||||||
| # of household moving into community this quarter | ||||||
| # of households evicted this quarter | ||||||
Sheet 5: Partners
| Partnerships for AHSSD Grant Program | ||||||
| Use this form to report information about partnerships supporting services to residents in AHSSD communities. For the first reporting period, please list all partners that will support the grant activities. For subsequent reports, please list only new partnerships that will support the grant activities. | ||||||
| Partner name | Partnership Start Date (MM/YYYY) | Types of Services Partner Will Provide to AHSSD Residents [Select all that apply: employment, education, financial, housing, health and social, civic engagement, support services, other (please describe in "Other Notes" section)] | Description of Services Partner Will Provide to AHSSD Participants | Will partner receive AHSSD funding for provision of these services? | Location of Service Delivery for AHSSD Residents | Other Notes |
Sheet 6: Characteristics
| Characteristics Data entry for individuals served by AHSSD this reporting period. |
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| Use this form to report the characteristics of individuals who have received services or referrals through the AHSSD grant project this reporting period. At the top of the form, you will provide the total number of unduplicated individuals and the households of those individuals who have received any services from the project. In the "Individual-Level Characteristics" section, you will provide the number of all individuals in the left-hand column and the number receiving intensive services in the right-hand column. In the "Household-Level Characteristics" section, you will report on the number of all households of individuals served in the left-hand column and the number of receiving intensive services in the right hand column. | ||||||||||||||||||
| Total unduplicated number of INDIVIDUALS who received services through the AHSSD grant this reporting period: | ||||||||||||||||||
| Total unduplicated number of all HOUSEHOLDS who received services from the AHSSD grant this reporting period: | ||||||||||||||||||
| INDIVIDUAL-LEVEL CHARACTERISTICS | HOUSEHOLD-LEVEL CHARACTERISTICS | |||||||||||||||||
| 1. Gender | Number of Individuals | Number Receiving Intensive Services | 5. Households with Children | Number of Households | Number Receiving Intensive Services | |||||||||||||
| a. | Male | a. | No children in household | |||||||||||||||
| b. | Female | b. | Children reside in household | |||||||||||||||
| c. | Other | c | TOTAL | 0 | 0 | |||||||||||||
| d. | Unknown | |||||||||||||||||
| e. | TOTAL | 0 | 0 | 6. Household Size | Number of Households | Number Receiving Intensive Services | ||||||||||||
| a. | Single Person | |||||||||||||||||
| 2. Age | Number of Individuals | Number Receiving Intensive Services | b. | Two | ||||||||||||||
| a. | 0-5 | c. | Three | |||||||||||||||
| b. | 6-13 | d. | Four | |||||||||||||||
| c. | 14-17 | e. | Five | |||||||||||||||
| d. | 18-24 | f. | Six or more | |||||||||||||||
| e. | 25-44 | g. | Unknown | |||||||||||||||
| f. | 45-54 | h. | TOTAL | 0 | 0 | |||||||||||||
| g. | 55-59 | |||||||||||||||||
| h. | 60-64 | 7. Level of Household Income | Number of Households | Number Receiving Intensive Services | ||||||||||||||
| i. | 65-74 | (% of HHS Guideline) | ||||||||||||||||
| j. | 75+ | a. | Up to 50% | |||||||||||||||
| k. | Unknown | b. | 51% to 75% | |||||||||||||||
| l. | TOTAL | 0 | 0 | c. | 76% to 100% | |||||||||||||
| d. | 101% to 125% | |||||||||||||||||
| 3. Education Levels | Number of Individuals | Number Receiving Intensive Services | e. | 126% to 150% | ||||||||||||||
| a. | Grades 0-8 | f. | 151% to 175% | |||||||||||||||
| b. | Grades 9-12/Non-Graduate | g. | 176% to 200% | |||||||||||||||
| c. | High School Graduate | h. | 201% to 250% | |||||||||||||||
| d. | GED/Equivalency Diploma | i. | 251% and over | |||||||||||||||
| e. | Some college | j. | Unknown | |||||||||||||||
| f. | College Graduate | k. | TOTAL | 0 | 0 | |||||||||||||
| g. | Graduate of other post-secondary school | |||||||||||||||||
| h. | Unknown | |||||||||||||||||
| i. | TOTAL | 0 | 0 | |||||||||||||||
| 4. Ethnicity/Race | Number of Individuals | Number Receiving Intensive Services | ||||||||||||||||
| a. Ethnicity | ||||||||||||||||||
| a.1. Hispanic, Latino or Spanish Origins | ||||||||||||||||||
| a.2. Not Hispanic, Latino or Spanish Origins | ||||||||||||||||||
| a.3. Unknown | ||||||||||||||||||
| a.4. TOTAL | 0 | 0 | ||||||||||||||||
| b. Race | ||||||||||||||||||
| b.1. American Indian or Alaska Native | ||||||||||||||||||
| b.2. Asian | ||||||||||||||||||
| b.3. Black or African American | ||||||||||||||||||
| b.4. Native Hawaiian and Other Pacific Islander | ||||||||||||||||||
| b.5. White | ||||||||||||||||||
| b.6. Other | ||||||||||||||||||
| b.7. Multi-race (two or more of the above) | ||||||||||||||||||
| b.8. Unknown | ||||||||||||||||||
| b.9. TOTAL | 0 | 0 | ||||||||||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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