Hud Xxxx Vawa Emergency Transfer Data Collection Form

VAWA EMERGENCY TRANSFER DATA COLLECTION FORM

U.S. Department Of Housing And Urban Development OMB Approval No. XXXX-XXX Exp. XXXX

Note: The information in this form may be collected by way of email communication, DocuSign, Microsoft Forms, or any other survey method collection. HUD may tailor this form to ask detailed questions by selecting different areas of this form as is relevant to their program area. These questions may also be embedded in existing checklists.

VAWA EMERGENCY TRANSFER DATA COLLECTION FORM

([INSERT RELEVANT HUD OFFICE])

BASIC INFORMATION:

Please provide information for the point of contact (POC) completing this form.

Name:

Email:

TYPE OF HOUSING PROVIDER: (Select all that apply.)

(Depending on which program is selected, program specific questions will be tailored to the response.)

1. Public Housing Authority

   1. Public Housing Program

   2. Housing Choice Voucher (HCV) Program (Including Project-based Vouchers (PBVs))

   3. Moderate Rehabilitation Program

2. Multifamily Owner or Manager

3. Continuum of Care (CoC) Recipient

4. Emergency Solutions Grants (ESG) Recipient

5. Rural Housing Stability Assistance Recipient

6. HOPWA Grantee

7. HOME Participating Jurisdiction/Housing Trust Fund Grantee

BASIC INFORMATION – Public Housing Agency (PHA)

PHA Name:

PHA Code:

BASIC INFORMATION – Multifamily Housing (MFH)

Information related to the collection of Emergency Transfer Data will be provided by Owners/Managers through form HUD-52670 as part of their monthly voucher.

BASIC INFORMATION – Continuum of Care (CoC)

CoC Number and Name:

Recipient/Subrecipient Name(s):

BASIC INFORMATION – Emergency Solutions Grants (ESG)

ESG Grantee:

Subrecipient Name(s):

BASIC INFORMATION – Rural Housing Stability Assistance Program

Recipient:

Subrecipient Name(s):

BASIC INFORMATION – Housing Opportunities for Persons With AIDS (HOPWA)

Grantee:

Project Sponsor(s):

BASIC INFORMATION – HOME Investment Partnerships Program (HOME)/Housing Trust Fund (HTF)

HOME Participating Jurisdiction:

HTF Grantee:

Section I: VAWA EMERGENCY TRANSFER PLANS

1. If you make your VAWA Emergency Transfer Plan publicly available on the internet, please provide the URL/internet address here: __________________________________________________________________________

2. If you do not make your VAWA Emergency Transfer Plan publicly available on the internet, please submit a copy of your current VAWA Emergency Transfer Plan when you submit this report to HUD.

3. If you do not make your VAWA Emergency Transfer Plan publicly available, please state why it is infeasible to make it publicly available.

___________________________________________________________________________

In the sections below, please provide data for emergency transfers under VAWA. Please see the Definitions section below for the definitions of the bolded and italicized terms.

Section II: TOTAL VAWA EMERGENCY TRANFER REQUESTS

4. Total Number of VAWA Emergency Transfer Requests

1. What is the total number of VAWA emergency transfer requests received during the current [ANNUAL OR MONTHLY] reporting period of [INSERT REPORTING TIME PERIOD]? _______

2. How many requests are pending review and pending approval from prior [YEARS OR MONTHS]?_______

3. Add together 4a and 4b to get the TOTAL number of VAWA emergency transfer requests for the reporting period of [INSERT REPORTING TIME PERIOD]. What is the combined number? ______

Section III: INCOMPLETE AND DENIED VAWA EMERGENCY TRANSFER REQUESTS

For the questions below, report on the status of the total number of VAWA emergency transfer requests from the reporting period in Question 4c.

5. Incomplete VAWA Emergency Transfer Requests

   1. How many VAWA emergency transfer requests for the reporting period (from 4c) were incomplete?______

   2. Identify the reasons the VAWA emergency transfer requests were incomplete and list the total number of requests for each outcome:

1. Housing provider was not able to reach tenant for follow up. _____

2. Housing provider’s VAWA Emergency Transfer Plan requires emergency transfer requests be in writing and the tenant did not provide the request in writing. _____

3. The tenant did not complete and submit the VAWA Self-Certification Form or provide other documentation of VAWA victim status after a written request from the housing provider. _____

4. Other ______

5. If “other”, please provide the reason(s) the VAWA emergency transfer requests were incomplete:

________________________________________________________________

6. How many VAWA emergency transfer requests for the reporting period (from 4c) were denied? _______

Section IV: APPROVED VAWA EMERGENCY TRANSFER REQUESTS

7. Number of Approved VAWA Emergency Transfer Requests

   1. How many VAWA emergency transfer requests (from 4c) were approved that were received during the current [ANNUAL OR MONTHLY] reporting time period of [INSERT REPORTING TIME PERIOD]? _______

   2. How many VAWA emergency transfer requests (from 4c) were approved that were pending review from prior reporting periods? ______

   3. How many VAWA emergency transfer requests (from 4c) were approved and pending placement from prior reporting periods? ______

   4. Add together 7a and 7b and 7c to get the TOTAL number of approved VAWA emergency transfer requests for the reporting period of [INSERT REPORTING TIME PERIOD]. What is the combined number? _____

8. For the questions below, report on the status of the total number of approved VAWA emergency transfer requests for the reporting period (from 7d).

   1. How many approved VAWA emergency transfer requests resulted in an internal transfer to a safe unit? ______

   2. How many approved VAWA emergency transfer requests resulted in an external transfer to a safe unit? _____

   3. How many approved VAWA emergency transfer requests are pending placement?_______

9. For approved VAWA emergency transfer requests (7d) that are pending placement, please identify the reason the requests are pending placement and list the total number of requests for each reason:

1. Awaiting placement for a safe unit ______

(This includes situations when the victim has a Housing Choice Voucher or other tenant-based assistance and is searching for a safe unit.)

2. Awaiting placement for a unit that meets occupancy standards_____

3. Awaiting placement for a unit that victim/household meets program eligibility requirements for _________

4. Awaiting a unit that meets the household’s accessibility needs _____

5. Awaiting issuance of a Housing Choice Voucher _____

6. Other _________

10. How many approved VAWA emergency transfer requests (from 7d) did not result in completed VAWA emergency transfer requests and the victim is no longer seeking an emergency transfer? _______

11. For approved VAWA emergency transfer requests that did not result in completed VAWA emergency transfer requests and which the victim is no longer seeking a transfer (from 10), please provide the total number of requests that failed to transfer for that reason:

1. Could not find a safe unit _____

2. Could not find an available unit _____

3. Could not find a unit that met occupancy standards _____

4. Could not find a unit that met the household’s accessibility needs _____

5. Victim/household’s program eligibility _____

6. No follow up from victim/household ______

7. Victim vacated unit ______

8. Victim withdrew the emergency transfer request and decided to remain in current unit ______

9. Other ______

If “other”, please describe the reason for the failures to transfer:

_____________________________________________________________

_____________________________________________________________

Section V: TIMEFRAMES OF VAWA EMERGENCY TRANSFER REQUEST

12. How long did it take for VAWA emergency transfer requests to be approved, denied, or determined to be incomplete after they were received (i.e. the time between when a request was expressly made to when the housing provider finished its review and (1) approved the request, (2) denied the request, or (3) determined that the request was incomplete)? List the number of VAWA emergency transfer requests for each timeframe below.

1. 0-7 calendar days ________

2. 8-14 calendar days_______

3. 15-30 calendar days ______

4. 31-90 calendar days ______

5. 91-120 calendar days __________

6. More than 120 calendar days______

13. How long does it take for VAWA emergency transfer requests to be completed after they were approved (i.e. the time between when a request was approved to when the tenant has moved into a safe unit)? List the number of VAWA emergency transfer requests for each timeframe below.

1. 0-7 calendar days ______

2. 8-14 calendar days______

3. 15-30 calendar days ______

4. 31-90 calendar days ______

5. 91-120 calendar days ________

6. More than 120 calendar days ________

14. What was the TOTAL length of time for VAWA emergency transfer requests to be completed after they were received (i.e. the time between when a request was expressly made to a housing provider to when the tenant has moved into a safe unit)? Please provide the number of VAWA emergency transfer requests for each timeframe below.

1. 0-7 calendar days ______

2. 8-14 calendar days______

3. 15-30 calendar days ______

4. 31-90 calendar days ______

5. 91-120 calendar days ________

6. More than 120 calendar days _______

Section VI:

15. Please check each item below that applies to you or is provided under your VAWA Emergency Transfer Plan:

[ ] We collaborate or coordinate with public housing authorities, Continuums of Care, owners/managers, consortiums, or other providers for purposes of providing housing and services for victims.

[ ] We offer interim housing for VAWA victims waiting for emergency transfers.

[ ] We provide a waitlist preference for victims of domestic violence, sexual assault, dating violence, and stalking.

[ ] We have a VAWA service coordinator or someone who functions as a VAWA service coordinator.

[ ] We conduct outreach activities to organizations that assist or provide resources to VAWA victims.

VAWA EMERGENCY TRANSFERS – SUB-QUESTIONS:

16. PHAs with a Stability Voucher (SV) Program

1. How many SVs were used to respond to a VAWA emergency transfer request? _____

2. How many of those SVs resulted in a completed VAWA emergency transfer request? _____

Definitions

Approved: An emergency transfer request is approved if the housing provider has finished its review of the emergency transfer request and has determined that the tenant is eligible for an emergency transfer under VAWA.

Completed: An emergency transfer request is completed when the victim has successfully been transferred to a safe unit.

Denied: An emergency transfer request is denied if the housing provider has finished its review of the transfer request and has determined that the tenant is ineligible for an emergency transfer request under VAWA (i.e. the incident or request is not covered under VAWA).

External Transfer: An external transfer refers to an emergency relocation of a tenant to another unit where the tenant would be categorized as a new applicant; that is, the tenant must undergo an application process in order to reside in the new unit.

Incomplete: An emergency transfer request is incomplete if the housing provider could not complete its review of the transfer request because the tenant did not submit necessary documentation or follow up to enable the housing provider’s review.

Internal Transfer: An internal transfer refers to an emergency relocation of a tenant to another unit where the tenant would not be categorized as a new applicant; that is, the tenant may reside in the new unit without having to undergo an application process.

Pending Placement: An emergency transfer request is pending placement if the housing provider has approved the emergency transfer request and the victim is waiting for permanent placement into a safe unit. This includes situations where a victim has a Housing Choice Voucher or other tenant-based assistance and is searching for a safe unit.

Pending Review: An emergency transfer request is pending review when the request has been expressly made and the housing provider is reviewing the request to determine whether a tenant is eligible for a VAWA emergency transfer request.

Received: An emergency transfer request is received when it is first expressly made to the housing provider for review. This includes if the request is made verbally, even if the housing provider’s VAWA Emergency Transfer Plan requires requests be made in writing.

Safe Unit: A safe unit is a housing unit that the victim believes is safe.

Public Reporting Burden for this collection of information is estimated to average 30 minutes to 60 minutes per response. This includes the time for collecting, reviewing, and reporting. Comments concerning the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to the Reports Management Officer, QDAM, Department of Housing and Urban Development, 451 7th Street, SW, Washington, DC 20410.  A Federal agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid Office of Management and Budget control number. 

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