10-0361-PDO Homeless Provider Grant and Per Diem Program - Per Diem

Department of Veterans Affairs

OMB Number 2900-0554
Estimated Burden: 20 hours

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in
accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. The
public reporting burden for this collection of information is estimated to average 20 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Respondents should be
aware that notwithstanding any other provision of law, no person will be subject to complete a collection of
information if it does not display a currently valid OMB control number. This collection of information is
intended to assist VA officials determine eligibility to receive grant and/or per diem payments and to rate
and rank these applications.

Homeless Provider Grant and
Per Diem Program
Per Diem Only
Application
Second Submission
VA Form
JAN 2003

10-0361 PDO

Per Diem Only Application:
Applicant Summary:
Application Project Number
Your Organization’s Name

Name & Title

Phone

Fax

Executive
Director/CEO
Person to contact
about application

1. Project Summary:
Our Organization requests per diem for: (check all that apply)
TRANSITIONAL HOUSING

SERVICE CENTER

1. The number of beds we are asking VA to fund is…
2a. The number of unique service center visits we are asking VA to fund per month is…
2b. The number of unique service center visits we are asking VA to fund per year is…
Consider agency to be a faith-based organization
Rural project location
Urban project location

A. Target Populations Below is a list of homeless veteran populations. Check those populations that you have
targeted to be served as a part of this application.
There is an expectation that if you identify a population to be served, the specific services (including staff) and/or
housing that meet the needs of the identified populations should be addressed in the project plan section of this
application. Failure to do so may decrease the overall score of the application.
Female homeless veterans
Frail and elderly homeless veterans
Terminally ill homeless veterans
Chronically mentally ill homeless veterans
HIV positive population
Veterans with PTSD diagnosis
Native American homeless veterans

Homeless veterans and their families
Homeless veterans with substance abuse problems
Homeless veterans with dual diagnosis
Veterans being released from prison
Disabled homeless veterans
Homeless veterans with mental illness
Other _____________________________________
(Please specify)

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B. Innovation of Project Complete this block if you want your project to be considered as innovative. (See
rules §61.13 (f) for innovative quality of proposal.)
Please consider this project for additional points for innovation because…

C. State/Local Government Applicants:
Applicants who are states or local governments must provide a copy of any comments or recommendations by
approved state and (area wide) clearinghouses pursuant to Executive Order 12372.

2. Major Milestones (Timeline):
Please enter the number of estimated days from execution of the per diem agreement that each of the
milestones will occur. (e.g., If execution of agreement is 9/30/99 and it will take 30 days for item one, enter:
30 days). Enter N/A if the event is not part of the proposal. (Please answer in the space provided below.)
Milestone

Days from Execution
of Per Diem Award

1. Operations Staff Hired
2. Residents begin to Occupy
3. Supportive Services Begin

3. Life Safety Code Notice:
If awarded, as a condition of funding all entities receiving grants and or per diem under PL 107-95 must ensure that
the project facilities meet the fire and safety requirements applicable under the Life Safety Code of the National Fire
Protection Association as well as any local or state codes as required. Failure to meet this requirement may lead to
loss of the award.

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4. Description of Need:
The information you provide here will assist in the rating of your project. Please provide a short and
descriptive narrative responding to each of the following items:
A. How did you identify the need for this project?
B. Estimate the total number of homeless veterans in your area that could be served by, or be eligible for, this
program and how many veterans from this population does this program intend on serving per year.
C. List the sources of this information. Please be specific. (Please answer in the space provided below.)

D. Describe any special characteristics or needs of this group to be served to demonstrate understanding of the
population. (Please answer in the space provided below.)

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5. Targeting:
A. Settings
The information you provide here will be used in rating targeting and quality of the project plan.
Complete the chart below, estimating the percentage of project participants who:
(Please answer in the space provided below.)

Projected Percentage
(must total 100%)
1. Regularly sleep in places not designed for, or ordinarily used as
sleeping accommodations for human beings.
2. Reside in an emergency shelter.
3. Are otherwise homeless.

B. Description of “Otherwise Homeless”:
(1.) If Item A, line 3, is greater than 0%, explain how participants will meet VA’s homeless definition.
(VA definition of homeless or homeless individual is located in the Rules and Regulations §61.1 Definitions.
Please answer in the space provided below.)

(2.)If you described an “otherwise homeless” population to be served, how will you determine that these
individuals actually need your services (i.e., would spend the night in a shelter or on the street)?
(Please answer in the space provided below.)

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5. Targeting (cont.):
C. Outreach Plan:
Please describe how your agency will identify and serve homeless veterans by responding to the
following 5 questions:
(1.) Briefly describe the veteran who would qualify for housing and/or services. Describe the process
your agency will use to screen homeless people for veteran status. (Please answer in the space provided below.)

(2.) a. Describe how your agency will reach out to homeless people living on the streets or in shelters.
b. How will you identify where homeless people can be found?
c. How will you sweep each site and engage the homeless to use your services?
(Please answer in the space provided below.)

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5C. Targeting (cont.):
(3.) In addition to outreach, are there other ways in which the homeless will access your services?
(Please answer in the space provided below.)

(4.) What initial services will you provide? (Please answer in the space provided below.)

(5.) Describe, if applicable, the population that you will serve that will not be veterans.
(Please answer in the space provided below.)

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6. Project Plan:
This is the portion of the application that describes your program, as VA Reviewers will focus on how the
project plan addresses the goals. The project plan section consists of 7 areas.
Please keep your answers within the boxed space provided after each question.
Area 1 questions begin with the goal. Be sure to address the goal in your answers.

Area 1. The information you provide here should relate to the following goals:
1. Residential stability of participants;
2. Increased skill level and/or income of participants; and
3. Greater self-determination of participants.
For each of the three goals listed above, describe in the space provided:
a)
b)
c)
d)

The specific measurable objective(s) that will be used to assess the program’s success,
How you decided on the objective(s)
How the success of the program will be evaluated on an ongoing basis, and
How you will determine whether program modifications are necessary, and if so, how such changes
will be implemented in order to make the program more fully realize its objectives.

BEGIN ON NEXT PAGE.

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6. Project Plan (cont.):
Area 1. (1a) The goal is residential stability of participants. - - What is/are the specific measurable objective(s)
that will be used to assess program success? (Please answer in the space provided below.)

Area 1. (1b) The goal is residential stability of participants - a. How will the objective(s) be achieved?
b. How will the success of the program be evaluated on an ongoing basis?
c. How will you determine whether program modifications are necessary, and if so how such changes will be
implemented to make the program fully realize its objectives? (Please answer in the space provided below.)

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6. Project Plan (cont.):
ATTENTION APPLICANT! YOU ARE BEGINNING A NEW GOAL.
Area 1. (2a) The goal is increased skill level and/or income of participants - - What are the specific measurable
objective(s) that will be used to assess the program’s success? (Please answer in the space provided below.)

Area 1. (2b) The goal is increased skill level and/or income of participants - a. How will the objective(s) be achieved?
b. How will the success of the program be evaluated on an ongoing basis?
c. How will you determine whether program modifications are necessary, and if so, how such changes will be
implemented in order to make the program fully realize its objectives? (Please answer in the space provided below.)

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6. Project Plan (cont.):
ATTENTION APPLICANT! YOU ARE BEGINNING A NEW GOAL.
Area 1. (3a) The goal is greater self-determination of participants - - What are the specific measurable
objective(s) that will be used to assess the program’s success? (Please answer in the space provided below.)

Area 1. (3b) The goal is greater self-determination of participants - a. How will the objective(s) be achieved?
b. How will the success of the program be evaluated on an on going basis?
c. How will you determine whether program modifications are necessary, and if so, how such changes will be
implemented in order to make the program fully realize its objectives? (Please answer in the space provided below.)

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6. Project Plan (cont.):
Area 2. Describe the process for assessing the initial service needs of potential participants in the program as
well as the process for assessing the ongoing needs of individuals once they become program participants.
(Please answer in the space provided below.)

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6. Project Plan (cont.):
Area 3. Provide a brief description of the supportive services to be offered participants and the way in which
supportive services will help participants meet the goals specified above. If the project will be providing case
management, describe how case management services will be provided in the program. Include in the
description the ratio of case managers to program participants. (Please answer in the space provided below.)

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6. Project Plan (cont.):
Area 4. Describe what role participants will have in governance of the program.
(Please answer in the space provided below.)

Area 5. Describe how this program will enable participants to gain greater access to neighborhood activities,
services, and institutions. (Please answer in the space provided below.)

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6. Project Plan (cont.):
Area 6. For applications proposing per diem for transitional housing, describe what permanent affordable
housing will be available to participants upon leaving transitional housing and how participants will be readied
for this event. (Please answer in the space provided below.)

Area 7. Describe any follow-up services that will be provided once participants leave transitional housing.
Include specific services to be provided. (Please answer in the space provided below.)

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7. Ability:
The information you provide here will be used in the rating of ability criterion. Please provide the
requested resumes and complete the questions within the boxed space that follows each question.
A. Experience of staff; please provide a one page resume of each key personnel. If your staff has not been
hired yet you may include a job description. (Attach here)

Describe the capacity of the organizations involved in carrying out this proposal in terms of:
B. Describe the experience of your organization in engaging the participation of homeless veterans residing in
places not ordinarily meant for human habitation or in emergency shelters. (Please answer in the space provided below.)

C. Describe the experience of your organization in assessing the housing and supportive service needs of
homeless veterans. (please answer in the space provided below.)

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7. Ability (cont.):
D. Describe the experience of your organization in accessing housing and supportive service resources,
including entitlement benefits. (Please answer in the space provided below.)

E. Describe the experience of your organization in providing supportive services to homeless persons that aid
them in achieving and maintaining stable long term housing; increasing their skill levels and income; and
gaining more influence over their lives. (Please answer in the space provided below.)

F. Describe the experience of your organization in monitoring and evaluating individuals' progress in meeting
personal goals. (Please answer in the space provided below.)

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7. Ability (cont.):
G. Describe the experience of your organization in evaluating overall effectiveness of programs and using the
evaluation to make improvements. (Please answer in the space provided below.)

H. For those programs' applications involving operation/maintenance of a housing facility, describe the
experience of your organization in operating housing for homeless persons. (Please answer in the space provided below.)

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8. Coordination with other Programs:
A. Attach here any VA or other coordination letters you have received in support of this project.

Please provide a description of each of the following in the box space provided:
B. How will program operations be integrated with existing services in the community (i.e., nonprofit
organizations and governmental entities, including VA medical facilities, VA regional offices, and your
Veterans Integrated Service Network (VISN)). (Please answer in the space provided below.)

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8. Coordination with other Programs (cont.):
C. How was the planning of this program coordinated with other organizations that assist the homeless. List
the primary agencies you work with that serve homeless veterans. Describe the nature and duration of your
relationship with them. (Please answer in the space provided below.)

D. Describe your involvement in VA-community networking for homeless veterans (e.g., Community
Homeless Assessment and Local Education and Networking Groups (CHALENG) for Veterans). Who is your
closest VA medical center or VA regional office CHALENG Point of Contact with whom you have networked?
(If you have not networked with your CHALENG Point of Contact, see the CHALENG Contact Person List and contact him or her.)
(Please answer in the space provided below.)

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9. Site Description:

(Please answer in the space provided below.)

A. Address of Site (please make sure actual address of site(s) is listed and not the address of the agency):

B. Photograph: attach a photograph of the site clearly showing the main entrance of the building(s) in the space
provided below.

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10. General Assurances:

All applicants must agree to the following assurances to VA as described below. No other format will be accepted as evidence of
reasonable assurances. Warning: Section 1001 of Title 18 of the United States Code (Criminal Code and Criminal Procedure) shall
apply to these assurances. Section 1001 of title 18 United States Code provides, that whoever knowingly and willfully makes or
uses a document or writing containing any false, fictitious, or fraudulent entry, in any matter within the jurisdiction of any
department or agency of the United States shall be fined not more than $ 10,000 or imprisoned not more than five years, or both.
A. Services Benefiting Veterans
If this proposal is funded applicant assures that upon
completion of the project:
1.

2.

3.
4.

5.

Programs so funded will be used principally to furnish
to veterans the level of care for which the application
was made at locations accessible to homeless veterans;
Not more than 25 percent of participants at any one time
will consist of participants who are not receiving such
services as veterans;
Services provided will meet standards prescribed by the
Secretary of Veterans Affairs;
Referral networks will be maintained for, and aid will
be given to, homeless veterans in establishing eligibility
for assistance and obtaining services under available
entitlement and assistance programs;
Confidentiality of records pertaining to homeless
veterans will be maintained in accordance with
applicable laws, Federal, State, and Local, (e.g.,
HIPAA, Privacy Act).

B. Reports; Record Retention
If this proposal is funded, applicants assure that any and all
reports required by the Secretary of Veterans affairs shall be
made in such form and contain such information as the
Secretary may require and /or are required by law. Applicant
further assures that upon demand, the Secretary of Veterans
Affairs has access to the records upon which such
information is based.

C. Continued Financial Support
If this proposal is funded, applicant assures that adequate
financial support will be available for the continued
maintenance, repair and operation of the project.
D. Fiscal Control
If this proposal is funded, applicant assures that it will
establish and maintain such procedures for fiscal control
and fund accounting as may be necessary to ensure proper
disbursement and accounting with respect to per diem
award.
E. Non-Delinquency
This institution certifies that it is not delinquent on any
Federal Debt and does not have any overdue or
unsatisfactory response to an audit. Applicant further
assures that they are not in default by failing to meet the
requirements of any previous assistance from VA.
F. Accuracy of Application Information
All information submitted with this application is accurate
and does not contain any false, fictitious, or fraudulent
statement or entry.
G. Compliance
Applicant assures that it will comply with applicable
requirements of 38 C.F.R. Part 61.

Signature of Authorized Certifying Official Title

Date

Applicant Organization

Date

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Application Assembly Checklist
Place your application in the order of the checklist below and list the page numbers in sequence on both
the application and on this checklist. The checklist will serve as your Table of Contents for your application
package. A page number box is at the bottom center of each application page. On documents you have
provided (i.e., assurances, resumes, etc.,) please place these documents in their proper order as directed in the
application (i.e., Attach Here) and number them in sequence. When finished your application should be
sequentially numbered, beginning at the first page and continuing through the last one submitted.
Items

VA Page Numbers

Applicant Page
Number

Applicant Summary - - PDO

PDO – page 1

Project Summary - - PDO
a. Target Populations
b. Innovation of Project
c. State and Local Govt. (if applicable)
Major Milestones (Timeline) - - PDO

PDO – pages 1 & 2

Description of Need - - PDO

PDO – page 3

Targeting - - PDO

PDO – pages 4 through 6

a. Settings
b. Description of ‘Otherwise Homeless’
c. Outreach Plan
Project Plan - - PDO
Areas 1 through 7
Ability - - PDO
a. Resumes of personnel
b. Questions B though H
Coordination with other Programs - - PDO
a. Question A Letters of Support
b. Questions B, C, & D
Site Description - - PDO
a. Address of site
b. Photograph of site
General Assurances - - PDO
Areas A through G
Application Assembly Checklist

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Applicant Page Number:

PDO – page 2

PDO – pages 7 through 14
PDO – pages 15 through 17

PDO – pages 18 & 19

PDO – page 20

PDO – page 21
PDO – page 22

Second Submission Page 22