Client Eligibility Documentation Form

Appendix B

Client Eligibility Documentation

Older Adults Home Modification Program

Client Eligibility Documentation¹

Study ID				Today’s Date	Form Completed By:
Site ID	Field Team ID	Client ID			Name	Job Title
						(dropdown menu: administrative staff, program staff, project manager, program manager, client services coordinator, OT, other [Specify])

OMB Control No. 2528-0335, expiration date 5/31/2025. This form is designed to provide HUD with information about the effectiveness of its Older Adults Home Modification Grant Program. 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  

Guidance Instructions : Please complete one form for each home you consider for inclusion in the OAHM program, even if none of the residents are found to be eligible. Enter information for one person per home, i.e., the person most likely to be the client (called the “potential client” in this form). Although items are numbered, you can complete this form in the order that makes the most sense for your program. Please provide an answer for each item.

1. Homeownership:

1. Did the potential client submit proof they own the home they would like to enroll in the program? ☐ yes ☐ no

2. Did the potential client submit proof they live in the home they would like to enroll in the program? ☐ yes ☐ no

2. Including the potential client, how many people live in this home? _______ (Answer must be at least 1)

3. Household Income:

(REDCap: List appropriate 80%, 50% and 30% AMI income levels according to the grantee’s location and the number of people living in the home based on Q2.)

Based on the answer to #2, is the potential client’s household annual income:

☐ Above the appropriate 80% AMI limit?

☐ Less than 80% AMI and above 50% AMI limit?

☐ Less than 50% AMI and above 30% AMI limit?

☐ Less than 30% AMI?

☐ Information not available

4. Does the physical condition of the potential client’s home meet the grantee’s eligibility criteria?

☐ yes ☐ no ☐ not applicable, home’s physical condition is not an eligibility criterion

5. Is the potential client most comfortable speaking in English, Spanish, or another language?

☐ English

☐ Spanish

☐ Another language not mentioned. Specify:_

6. Age Questions:

   1. What is the potential client’s age (in years)? _________

   2. What is the potential client’s birthdate (mm/dd/yyyy)?

7. Is the potential client ineligible due to organization-specific eligibility criteria not mentioned above? ☐ Yes (Specify)

☐ No ☐ NA, there were no other organization-specific criteria

8. Is the potential client eligible for the program? ☐ yes Go to 9 ☐ no Complete a Lost to Project

9. Grantee Instructions: Complete the following information only after an individual has been found eligible for the program. If more than one OAHMP-eligible person lives in the home AND the licensed occupational therapist (OT) [or licensed OT Assistant (OTA) or Certified Aging-in-Place Specialist (CAPS) whose work is overseen by a licensed OT] determines the other resident should receive OAHMP services, i.e., the OT/OTA/CAPS-identified client is different from the individual whose data was entered in questions 5 and 6, please revise those questions to answer them for the identified client and update form with correct “client” name.

1. Name of Client:

2. Primary Residence Address:

Street Number and Name:

Unit Number:

City: ___________________________ State: Zip Code:

3. Phone Information.

9.c.i Check this box if the client does not have a phone: ☐ (Do not allow the phone number questions to be filled in, skip to 9d)

9.c.ii Check this box if the client needs to use TTY or TDD services: ☐

Teletype (TTY) or Telecommunications Device for the Deaf (TDD) number: ________________

9.c.iii Phone number to reach client during the day:

Preferred contact method? ☐ yes ☐ no

Does client prefer to receive calls or texts on this phone? (Check “Calls” if the phone is not a cell phone) ☐ Calls ☐ Texts ☐ No preference

9.c.iv Phone number to reach client in the evening:

Preferred contact method: ☐ yes ☐ no

Does client prefer to receive calls or texts on this phone? (Check “Calls” if the phone is not a cell phone) ☐ Calls ☐ Texts ☐ No preference

4. Email information: check this box if client does not have an email address: ☐ (Do not allow the email address questions to be filled in)

Email address:

Preferred contact method: ☐ yes ☐ no

Sociodemographic Questions²

Questions 9.e through 9i may be asked of the client either in person or by phone.

5. What is your gender: (List answer here)______________________

☐ Not answered

6. Do you consider yourself Hispanic or Latino?(NHATS, HRS)

☐ Yes

☐ No

☐ Not answered

7. What race do you consider yourself to be? (NHATS and HRS) If you are completing this form this in person, hand client answer card D or read options verbatim. Tell client they may select one or more categories. (Allow check all that apply)

☐ White

☐ Black or African American

☐ American Indian

☐ Alaska Native

☐ Asian

☐ Native Hawaiian

☐ Pacific Islander

☐ Something else ___________

☐ Not answered

8. What is the highest grade in school you completed? Check one box

☐ less than 12 years

☐ high school graduate or GED

☐ some college or trade school

☐ Associate’s Degree

☐ Bachelor's Degree

☐ Master's Degree

☐ Doctorate or Other Professional Degree

☐ Not answered

9. What is your marital status?

☐ Single, never married

☐ Married or domestic partnership

☐ Widowed

☐ Divorced

☐ Separated

☐ Not Answered

10. Who lives with you in this same house?

REDCap: The following instruction applies to all answer choices except “No one else, Professional Caregiver, or Not Answered”: For each person checked, open the “# ≥62____” box to record the number of people in that category who are 62 or older.

☐ No one else, I live alone

☐ Child(ren) (Son/Daughter) # ≥62___

☐ Spouse # ≥62___

☐ Parent(s) # ≥62___

☐ Grandchild(ren) # ≥62___

☐ Other Relative(s) # ≥62___

☐ Other Individuals # ≥62___

☐ Professional Caregiver

☐ Not answered

Contact Notes (e.g., list any hearing, vision, or speech issues field staff may need to consider when contacting or visiting the client):

CLIENT ELIGIBILITY ANSWER CARD

Client Eligibility ANSWER CARD D

(may choose more than one option)

• White

• Black or African American

• American Indian

• Alaska Native

• Asian

• Native Hawaiian

• Pacific Islander

• Something else ___________

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

2 THIS IS NOT AN OFFICIAL GOVERNMENT SURVEY.